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Reducing Antacid Use in a Level IV NICU: A QI Project to Reduce Morbidity. Pediatr Qual Saf 2020; 5:e303. [PMID: 32607459 PMCID: PMC7297399 DOI: 10.1097/pq9.0000000000000303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids. Methods A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record. Results Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days). Conclusions A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.
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Marker S, Barbateskovic M, Perner A, Wetterslev J, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2020; 64:714-728. [PMID: 32060905 DOI: 10.1111/aas.13568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/12/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients. METHODS We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials. RESULTS We included 65 comparisons from 62 trials (n = 9713); 43 comparisons were from intensive care units. Only three trials (n = 3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses. CONCLUSIONS We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive. STUDY REGISTRATION PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Marija Barbateskovic
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Department of Cardiology Holbaek Hospital Holbaek Denmark
- Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Mette Krag
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Carl T. Anthon
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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Zaragoza R, Vidal-Cortés P, Aguilar G, Borges M, Diaz E, Ferrer R, Maseda E, Nieto M, Nuvials FX, Ramirez P, Rodriguez A, Soriano C, Veganzones J, Martín-Loeches I. Update of the treatment of nosocomial pneumonia in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:383. [PMID: 32600375 PMCID: PMC7322703 DOI: 10.1186/s13054-020-03091-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/12/2020] [Indexed: 12/19/2022]
Abstract
In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign and the recently published European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. The aim of this manuscript is to update treatment protocols by reviewing recently published studies on the treatment of nosocomial pneumonia in the critically ill patients that require invasive respiratory support and patients with HAP from hospital wards that require invasive mechanical ventilation. An interdisciplinary group of experts, comprising specialists in anaesthesia and resuscitation and in intensive care medicine, updated the epidemiology and antimicrobial resistance and established clinical management priorities based on patients' risk factors. Implementation of rapid diagnostic microbiological techniques available and the new antibiotics recently added to the therapeutic arsenal has been reviewed and updated. After analysis of the categories outlined, some recommendations were suggested, and an algorithm to update empirical and targeted treatment in critically ill patients has also been designed. These aspects are key to improve VAP outcomes because of the severity of patients and possible acquisition of multidrug-resistant organisms (MDROs).
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Affiliation(s)
- Rafael Zaragoza
- Critical Care Department, Hospital Universitario Dr. Peset, Valencia, Spain. .,Fundación Micellium, Valencia, Spain.
| | | | - Gerardo Aguilar
- SICU, Hospital Clínico Universitario Valencia, Valencia, Spain
| | - Marcio Borges
- Fundación Micellium, Valencia, Spain.,ICU, Hospital Universitario Son Llázter, Palma de Mallorca, Spain
| | - Emili Diaz
- Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain.,CIBERES Ciber de Enfermedades Respiratorias, Madrid, Spain
| | | | - Emilio Maseda
- Fundación Micellium, Valencia, Spain.,SICU, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Nieto
- ICU, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Paula Ramirez
- ICU, Hospital Universitari I Politecnic La Fe, Valencia, Spain
| | | | - Cruz Soriano
- ICU, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ignacio Martín-Loeches
- ICU, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
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GÜNDOĞAN K, KARAKOÇ E, TEKE T, ZERMAN A, ESMAOĞLU A, TEMEL Ş, GÜVEN M, SUNGUR M. Effects of oral/enteral nutrition alone versus plus pantoprazole on gastrointestinal bleeding in critically ill patients with low risk factor: a multicenter, randomized controlled trial. Turk J Med Sci 2020; 50:776-783. [PMID: 32151119 PMCID: PMC7379460 DOI: 10.3906/sag-1911-42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/05/2020] [Indexed: 01/14/2023] Open
Abstract
Background/aim Critically ill patients are at risk of developing gastrointestinal (GI) bleeding due to stress causing mucosal damage. Aim of the study was to determine the effect of oral/enteral nutrition with or without concomitant pantoprazole on upper GI bleeding in low risk critically ill patients. Materials and methods This was a prospective, randomized, open-label, multicenter study conducted with intensive care unit (ICU) patients receiving oral/enteral nutritional support. Patients were randomly assigned into two groups including intervention group (received oral/EN plus pantoprazole) and control group (received only oral/EN). Results A total of 300 patients (intervention group: 152, control group: 148) participated in the study. Overall, 226 (75%) patients were fed by orally and 74 (25%) patients fed by enteral tube feeding. Median duration of nutritional support 4 (range: 2–33) days. Overt upper GI bleeding was noted only in one patient (0.65%) who was in the intervention group. The overall length of ICU stay of 4 (2–105) days, while ICU stay was significantly longer in the intervention group than in the control group (P = 0.006). Conclusions Our findings seems to indicate that in patients who are at low risk for GI bleeding and under oral/enteral nutritional support, the use of PPIs may not reduce the risk of bleeding, however these results are imprecise because of low event (GI bleeding) rate and limited power.
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Affiliation(s)
- Kürşat GÜNDOĞAN
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Emre KARAKOÇ
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Çukurova University, AdanaTurkey
| | - Turgut TEKE
- Division of Intensive Care, Department of Pulmonary Disease, Faculty of Medicine, Necmettin Erbakan University, KonyaTurkey
| | - Avşar ZERMAN
- Intensive Care Unit, Department of Internal Medicine, Ministry of Health Adana Numune Training and Educational Hospital, AdanaTurkey
| | - Aliye ESMAOĞLU
- Division of Intensive Care, Department of Anesthesiology and Reanimation, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Şahin TEMEL
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Muhammet GÜVEN
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Murat SUNGUR
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
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Wang YT, Tsai MC, Wang YH, Wei JCC. Association Between Proton Pump Inhibitors and Asthma: A Population-Based Cohort Study. Front Pharmacol 2020; 11:607. [PMID: 32457614 PMCID: PMC7227244 DOI: 10.3389/fphar.2020.00607] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
Objective The relationship between proton pump inhibitors (PPIs) and asthma is controversial. The goal of this study was to determine the association between PPI use in non-asthma subjects and their subsequent asthma prevalence. Design Nationwide, population-based cohort study. Methods We conducted a nationwide, population-based retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) of Taiwan from 1999 to 2013. We identified 24,077 adult patients with PPI use for more than 3 months and 24,077 controls matched by propensity score on a one-to-one ratio for age, gender, comorbidities (hypertension, hyperlipidemia, gastroesophageal reflux disease, allergic rhinitis, atopic dermatitis, peptic ulcer disease, diabetes, and sleep apnea syndrome), and medications (histamine 2 receptor antagonists [H2RA], nonsteroidal anti-inflammatory drugs [NSAIDs], and acetaminophen). The cumulative asthma incidence for the two cohorts in the follow-up period was estimated with the Kaplan-Meier method, and the difference was examined using the log-rank test. Multivariate Cox regression models were used to calculate the adjusted hazard ratios (HR). Results The overall incidence of asthma was 1.58-fold greater in the PPI cohort than in the non-PPI cohort (13.3 versus 8.4 per 1,000 person-years), with an adjusted HR of 1.76 (95% confidence interval [CI], 1.64-1.88). In patients without previous peptic ulcer disease, the adjusted HR of asthma associated with PPIs was higher than in the non-PPI group (1.95; 95% CI, 1.80-2.11). The risk of asthma due to PPI use was also more significant in patients not receiving H2RA (1.81; 95% CI, 1.66-1.96), NSAIDs (1.93; 95% CI, 1.73-2.15), and acetaminophen (1.88; 95% CI, 1.70-2.08). Conclusions This population base study demonstrated that patients with long-duration of PPI use are at a higher risk of developing asthma, regardless of age, gender, comorbidities, and medications.
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Affiliation(s)
- Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Abstract
PURPOSE OF REVIEW Change of practice in the ICU, particularly the discontinuation of approaches, which are no longer felt to be beneficial, can be challenging. This review will examine this issue and outline current thinking regarding how to best approach it. RECENT FINDINGS Practices in medicine that do not provide patients benefit and possibly cause harm exist throughout medicine and are called low-value practices. Some low-value practices have successfully been removed from the ICU whereas others remain. The process of removing these practices from established care is often called deadoption. Low-value practices that are simply ineffective but produce comparatively less harm or cost, may represent a significant challenge to deadoption. Additionally, although no single intervention has been identified as the preferred method of deadoption of a low-value practice, we advocate for a multimodal approach. SUMMARY Deadoption in the intensive care unit of practices that either cause harm or are significantly costly relative to their benefit remains an elusive goal. Attempts at deadoption should target local ICU circumstances, while still encompassing the spectrum of care outside the ICU, engage nursing more fully, promote the use of local champions, especially peers, and recognize the requirement to seek sustainability.
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Dargent A, Jacquier M, Rozencwajg S, Andreu P, Quenot JP. Stress ulcer prophylaxis in ICU patients: Answers and questions from the PEPTIC trial. Anaesth Crit Care Pain Med 2020; 39:175-177. [PMID: 32147580 DOI: 10.1016/j.accpm.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Auguste Dargent
- Médecine Intensive Réanimation, Hôpital Édouard-Herriot, 69003 Lyon, France
| | - Marine Jacquier
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Sacha Rozencwajg
- Service de Réanimation Chirurgicale, CHU Bichat-Claude-Bernard, 75018 Paris, France; Junior Group of the French Society of Anaesthesia and Intensive Care Medicine (Groupe Jeunes de la SFAR), 75016 Paris, France
| | - Pascal Andreu
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, CHU Dijon-Bourgogne, 21000 Dijon, France; INSERM, U1231, Équipe Lipness, Université Bourgogne-Franche-Comté, 21000 Dijon, France; INSERM, CIC-EC 1432, Faculté des sciences de la santé, 21000 Dijon, France.
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58
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Rice TW, Kripalani S, Lindsell CJ. Proton Pump Inhibitors vs Histamine-2 Receptor Blockers for Stress Ulcer Prophylaxis in Critically Ill Patients: Issues of Interpretability in Pragmatic Trials. JAMA 2020; 323:611-613. [PMID: 31950973 DOI: 10.1001/jama.2019.22436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J Lindsell
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
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Laoveeravat P, Thavaraputta S, Vutthikraivit W, Suchartlikitwong S, Mingbunjerdsuk T, Motes A, Nugent K, Rakvit A, Islam E, Islam S. Proton pump inhibitors and histamine-2 receptor antagonists on the risk of pancreatic cancer: a systematic review and meta-analysis. QJM 2020; 113:100-107. [PMID: 31503318 DOI: 10.1093/qjmed/hcz234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 08/30/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) have been widely used for multiple purposes. Recent studies have suggested an association between these medications and the risk of pancreatic cancer. However, the results have been inconclusive. AIM We, therefore, conducted a study to assess the risk of developing pancreatic cancer in patients who used PPI and H2RA. DESIGN A systematic review and meta-analysis. METHODS A literature search was performed using MEDLINE and EMBASE databases from inception through February 2019. Studies that reported risk ratio comparing the risk of pancreatic cancer in patients who received PPI or H2RA versus those who did not receive treatments were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effect generic inverse variance method. Sensitivity analysis, excluding one study at a time, was performed. RESULTS After screening abstracts from the searching methods, seven studies (six case-control studies and one cohort study) were included in the analysis with total 546 199 participants. Compared to patients who did not take medications, the pooled RR of developing pancreatic cancer in patients receiving PPI and H2RA were 1.73 (95% CI: 1.16-2.57) and 1.26 (95% CI: 1.02-1.57), respectively. However, the sensitivity analysis of PPI changed the pooled RR to 1.87 (95% CI: 1.00-3.51) after a study was dropped out. Likewise, H2RA sensitivity analysis also resulted in non-significant pooled RR. CONCLUSIONS This meta-analysis did not find the strong evidence for the associations between the use of PPI and H2RA and pancreatic cancer.
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Affiliation(s)
- P Laoveeravat
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - S Thavaraputta
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - W Vutthikraivit
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - S Suchartlikitwong
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - T Mingbunjerdsuk
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - A Motes
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - K Nugent
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - A Rakvit
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - E Islam
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - S Islam
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Ogasawara O, Kojima T, Miyazu M, Sobue K. Impact of the stress ulcer prophylactic protocol on reducing the unnecessary administration of stress ulcer medications and gastrointestinal bleeding: a single-center, retrospective pre-post study. J Intensive Care 2020; 8:10. [PMID: 31988751 PMCID: PMC6966877 DOI: 10.1186/s40560-020-0427-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022] Open
Abstract
Background Clinically significant gastrointestinal bleeding from stress ulcers increases patient mortality in intensive care, and histamine type 2 receptor blockers and proton pump inhibitors as stress ulcer prophylaxes were reported to decrease the incidence of that. Although medical checklists are widely used to maintain high compliance with medications and interventions to improve patient outcome in the intensive care field, the efficacy of medical checklists regarding the incidence of gastrointestinal bleeding and the reduction of unnecessary administration of stress ulcer prophylaxis medications has not been sufficiently explored to date. This study aimed to investigate the incidence of gastrointestinal bleeding and the rate of administering stress ulcer prophylaxis medication before and after setting administration criteria for stress ulcer prophylaxis and introducing a medical checklist for critically ill adults. Methods This was a retrospective pre-post study at a single-center, tertiary adult and pediatric mixed ICU. Adult patients (≥ 18 years) who were admitted to the ICU for reasons other than gastrectomy, esophagectomy, pancreatoduodenectomy, and gastrointestinal bleeding were analyzed. A medical checklist and stress ulcer prophylaxis criteria were introduced on December 22, 2014, and the patients were classified into the preintervention group (from September to December 21, 2014) and the postintervention group (from December 22, 2014, to April 2015). The primary outcome was the incidence of upper gastrointestinal bleeding, and the secondary outcome was the proportion administered stress ulcer prophylaxis medications. Results One hundred adult patients were analyzed. The incidence of upper gastrointestinal bleeding in the pre- and postintervention groups was both 4.0% [95% confidence interval, 0.5–13.7%]. The proportion administered stress ulcer prophylaxis medications decreased from 100 to 38% between the pre- and post-intervention groups. Conclusions After the checklist and the criteria were introduced, the administration of stress ulcer prophylaxis medications decreased without an increase in upper gastrointestinal bleeding in critically ill adults. Prospective studies are necessary to evaluate the causal relationship between the introduction of them and gastrointestinal adverse events in critically ill adults.
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Affiliation(s)
- Osamu Ogasawara
- 1Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601 Japan
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, 7-426, Morioka-cho, Obu, Aichi 474-0031 Japan
| | - Mitsunori Miyazu
- Department of Anesthesiology, Aichi Children's Health and Medical Center, 7-426, Morioka-cho, Obu, Aichi 474-0031 Japan
| | - Kazuya Sobue
- 1Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601 Japan
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A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system. Infect Control Hosp Epidemiol 2020; 41:547-552. [DOI: 10.1017/ice.2019.368] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP).Design:Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients.Setting:All 21 hospitals of an integrated healthcare system with 4.4 million members.Patients:All hospitalized patients.Interventions:Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care.Results:HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439).Conclusion:HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.
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Wang Y, Ye Z, Ge L, Siemieniuk RAC, Wang X, Wang Y, Hou L, Ma Z, Agoritsas T, Vandvik PO, Perner A, Møller MH, Guyatt GH, Liu L. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis. BMJ 2020; 368:l6744. [PMID: 31907166 PMCID: PMC7190057 DOI: 10.1136/bmj.l6744] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS We included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates. RESULTS Seventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence). CONCLUSIONS For higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019126656.
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Affiliation(s)
- Ying Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhikang Ye
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Xin Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yingkai Wang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liangying Hou
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhuo Ma
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Division of General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Lihong Liu
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Sattayalertyanyong O, Thitilertdecha P, Auesomwang C. The inappropriate use of proton pump inhibitors during admission and after discharge: a prospective cross-sectional study. Int J Clin Pharm 2019; 42:174-183. [PMID: 31865594 DOI: 10.1007/s11096-019-00955-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/13/2019] [Indexed: 12/11/2022]
Abstract
Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand's largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.
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Affiliation(s)
- Onuma Sattayalertyanyong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Premrutai Thitilertdecha
- Research Group in Immunobiology and Therapeutic Sciences, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chonticha Auesomwang
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Kanno T, Moayyedi P. Proton Pump Inhibitors in the Elderly, Balancing Risk and Benefit: an Age-Old Problem. Curr Gastroenterol Rep 2019; 21:65. [PMID: 31807948 DOI: 10.1007/s11894-019-0732-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Proton pump inhibitors (PPIs) are one of the most prescribed drugs in the developed world and elderly patients are particularly likely to be prescribed acid suppression. There have been reports of many diseases being associated with PPI therapy and the elderly would be particular at risk of any harms these drugs may cause. This review therefore reviews the evidence of the risks and benefits of these drugs. RECENT FINDINGS PPIs are very effective at treating acid-related disorders. Recent randomized trials have suggested that the associations between PPI and various diseases are likely to be related to bias and residual confounding and these drugs appear to be safe apart from a possible increase risk of enteric infections. PPIs should be used at the lowest dose and for the shortest duration possible. They are still relatively safe drugs but should only be prescribed for proven indications.
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Affiliation(s)
- Takeshi Kanno
- Farncombe Family Digestive Health Research Institute, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada
| | - Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
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Rieckert A, Becker A, Donner-Banzhof N, Viniol A, Bücker B, Wilm S, Sönnichsen A, Barzel A. Reduction of the long-term use of proton pump inhibitors by a patient-oriented electronic decision support tool (arriba-PPI): study protocol for a randomized controlled trial. Trials 2019; 20:636. [PMID: 31752978 PMCID: PMC6868794 DOI: 10.1186/s13063-019-3728-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool. METHODS The arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient. DISCUSSION Our principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care. TRIAL REGISTRATION German Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.
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Affiliation(s)
- Anja Rieckert
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448 Witten, Germany
| | - Annette Becker
- Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-von-Frisch Str. 4, 35043 Marburg, Germany
| | - Norbert Donner-Banzhof
- Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-von-Frisch Str. 4, 35043 Marburg, Germany
| | - Annika Viniol
- Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Karl-von-Frisch Str. 4, 35043 Marburg, Germany
| | - Bettina Bücker
- Institute of General Practice, Centre for Health and Society, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Stefan Wilm
- Institute of General Practice, Centre for Health and Society, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Andreas Sönnichsen
- Department of General Practice and Family Medicine, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15/I, 1090 Vienna, Austria
| | - Anne Barzel
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448 Witten, Germany
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Mueller S, Zheng J, Orav EJ, Schnipper JL. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Qual Saf 2019; 28:e1. [PMID: 30257883 PMCID: PMC11128274 DOI: 10.1136/bmjqs-2018-008087] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. OBJECTIVE To evaluate the association between IHT and healthcare utilisation and clinical outcomes. DESIGN Retrospective cohort. SETTING CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. PARTICIPANTS Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories. MAIN OUTCOME MEASURES Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients. RESULTS The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). CONCLUSIONS In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.
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Affiliation(s)
- Stephanie Mueller
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
| | - Jie Zheng
- Harvard School of Public Health, Department of Health Policy and Management, Boston, Massachusetts, USA
| | - Endel John Orav
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
- Harvard School of Public Health, Department of Health Policy and Management, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
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Srinutta T, Chewcharat A, Takkavatakarn K, Praditpornsilpa K, Eiam-Ong S, Jaber BL, Susantitaphong P. Proton pump inhibitors and hypomagnesemia: A meta-analysis of observational studies. Medicine (Baltimore) 2019; 98:e17788. [PMID: 31689852 PMCID: PMC6946416 DOI: 10.1097/md.0000000000017788] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous meta-analyses have suggested that there might be an association between the use of proton pump inhibitors (PPIs) and the development of hypomagnesemia, although the conclusions were no definitive. METHODS To provide an update on this topic, we performed a meta-analysis of all observational studies that examined the association between the use of PPIs and the development of hypomagnesemia. A literature search was conducted in MEDLINE, Scopus and Cochrane Central Register of Controlled Trials (January 1970 to June 2018) to identify observational studies that examined the association between the use of PPIs and the incidence and prevalence of hypomagnesemia. STUDY ELIGIBILITY CRITERIA In the absence of randomized controlled trials, we focused primarily on observational studies, including cross-sectional, case-control, retrospective, and prospective cohort studies. There was no limitation on sample size or study duration. Random-effect models meta-analyses were used to compute pooled unadjusted and adjusted odds ratios (ORs) for binary variables. RESULTS Sixteen observational studies were identified, including 13 cross-sectional studies, 2 case-control studies, and 1 cohort study, with a total of 131,507 patients. The pooled percentage of PPI users was 43.6% (95% confidence interval [CI] 25.0%, 64.0%). Among PPI users, 19.4% (95% CI 13.8%, 26.5%) had hypomagnesemia compared to 13.5% (95% CI 7.9%, 22.2%) among nonusers. By meta-analysis, PPI use was significantly associated with hypomagnesemia, with a pooled unadjusted OR of 1.83 (95% CI 1.26, 2.67; P = .002) and a pooled adjusted OR of 1.71 (95% CI 1.33, 2.19; P < .001). In subgroup analyses, high-dose PPI use was associated with higher odds for hypomagnesemia relative to low-dose PPI use (pooled adjusted OR 2.13; 95% CI 1.26, 3.59; P = .005). CONCLUSION Our findings are in support of the results of the previous meta-analyses. Furthermore, we found a dose-response between the PPI use and development of hypomagnesemia.
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Affiliation(s)
- Thawin Srinutta
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Api Chewcharat
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth's Medical Center
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Research Unit for Metabolic Bone Disease in CKD patients, Chulalongkorn University, Bangkok, Thailand
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68
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Snapshot of proton pump inhibitors prescriptions in a tertiary care hospital in Switzerland: less is more? Int J Clin Pharm 2019; 41:1634-1641. [DOI: 10.1007/s11096-019-00929-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/17/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background Proton pump inhibitors are among the most widely prescribed drugs in the world, but more than half of the indications for prescription are unjustified. The misuse of this therapeutic class has heavy consequences such as additional health costs, adverse drug reactions following long-term use and gastric acid rebound when the proton pump inhibitor is discontinued. Objective The overprescription of proton pump inhibitors is therefore becoming a public health problem, which led us to evaluate their use within the Geneva University Hospitals. Setting Patients hospitalized in two divisions of the department of internal medicine of the Geneva University Hospitals on a single day. Methods This is a register-based cross-sectional study and it collected data about the prescription pattern of proton pump inhibitors by consulting the electronic records of patients included. Main outcome measure To determine if the proton pump inhibitors prescription is made according to the market authorization and the available guidelines. Results Hundred-eighty patients were included. 54% of patients were on proton pump inhibitors, 29% of whom had their treatment initiated at hospital. Of the indications for treatment, 72% were not justified and 63% of the justified indications did not have an adequate dosage. Therefore, in all patients with a proton pump inhibitor at hospital, only 11% had a justified indication with an adequate dose. Finally, 87% of known home prescriptions were renewed on admission and among them, 71% did not have a justified or possibly justified indication according to the guidelines. Conclusion Indication for treatment inside the hospital was not justified in 72% of patients and only 11% had a justified indication with an adequate dosage. Precise guidelines with evidence-based indications and adequate daily doses would help to correctly prescribe proton pump inhibitors. Moreover, patients should benefit from a thorough evaluation of their treatment.
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69
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Rodriguez AE, Restrepo MI. New perspectives in aspiration community acquired Pneumonia. Expert Rev Clin Pharmacol 2019; 12:991-1002. [PMID: 31516051 DOI: 10.1080/17512433.2019.1663730] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Aspiration pneumonia is a subclass of community-acquired pneumonia that is expected to have an increasing contribution in mortality and morbidity, particularly in the elderly population over the next coming decades. While studies have revealed significant progress in identifying risk factors for aspiration pneumonia, the clinical presentation and diagnosis remain challenging to healthcare providers. Areas covered: We conducted a broad literature review using the MeSH heading in PubMed/MEDLINE of 'aspiration pneumonia' from January 1970 to July 2019. The understanding of the microbiology of aspiration pneumonia has evolved from a possible shift in the causative organisms away from anaerobes to traditional community-acquired pneumonia organisms. The importance of this shift is not yet known, but it has questioned the pathogenic role of anaerobes, appropriate anaerobic testing and the role of these pathogens in the pulmonary microbiome in patients with pneumonia. The identification of risk factors led to strategies to prevent or minimize the risk of aspiration pneumonia with moderate success. Expert opinion: Our expert opinion is that further research is needed to determine the role of the microbiome with aspiration pneumonia and patient risk factors. There is also a great need to develop clinical tools to help providers diagnose, treat, and prevent aspiration pneumonia.
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Affiliation(s)
- Abraham E Rodriguez
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health , San Antonio , TX , USA.,Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System , San Antonio , TX , USA
| | - Marcos I Restrepo
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health , San Antonio , TX , USA.,Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System , San Antonio , TX , USA
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Abstract
Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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71
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Lanas-Gimeno A, Hijos G, Lanas Á. Proton pump inhibitors, adverse events and increased risk of mortality. Expert Opin Drug Saf 2019; 18:1043-1053. [DOI: 10.1080/14740338.2019.1664470] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Gonzalo Hijos
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
- CIBERehd, Madrid, Spain
- Department of Medicine, Universidad de Zaragoza, Zaragoza, Spain
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Mafi JN, May FP, Kahn KL, Chong M, Corona E, Yang L, Mongare MM, Nair V, Reynolds C, Gupta R, Damberg CL, Esrailian E, Sarkisian C. Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. J Am Geriatr Soc 2019; 67:2600-2604. [PMID: 31486549 DOI: 10.1111/jgs.16117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced-based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline-based (1) short-term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long-term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger-Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low-value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%-40.7%) were potentially low value-of which 82% began appropriately (eg, GERD) but then continued long term without a guideline-based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low-value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one-third of prescriptions were potentially low-value. Most often, appropriate short-term prescriptions became potentially low value because they lacked long-term indications. With most potentially low-value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR-based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600-2604, 2019.
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Affiliation(s)
- John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.,RAND Corporation, Santa Monica, California
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Katherine L Kahn
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.,RAND Corporation, Santa Monica, California
| | - Michelle Chong
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Edgar Corona
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Liu Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Margaret M Mongare
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Vishnu Nair
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Courtney Reynolds
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Reshma Gupta
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Eric Esrailian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at UCLA and Veterans Affairs (VA) Greater Los Angeles Healthcare System Geriatric Research Education and Clinical Center, Los Angeles, California
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Moayyedi P, Eikelboom JW, Bosch J, Connolly SJ, Dyal L, Shestakovska O, Leong D, Anand SS, Störk S, Branch KRH, Bhatt DL, Verhamme PB, O'Donnell M, Maggioni AP, Lonn EM, Piegas LS, Ertl G, Keltai M, Bruns NC, Muehlhofer E, Dagenais GR, Kim JH, Hori M, Steg PG, Hart RG, Diaz R, Alings M, Widimsky P, Avezum A, Probstfield J, Zhu J, Liang Y, Lopez-Jaramillo P, Kakkar AK, Parkhomenko AN, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Vinereanu D, Tonkin AM, Lewis BS, Felix C, Yusoff K, Metsarinne KP, Fox KAA, Yusuf S. Safety of Proton Pump Inhibitors Based on a Large, Multi-Year, Randomized Trial of Patients Receiving Rivaroxaban or Aspirin. Gastroenterology 2019; 157:682-691.e2. [PMID: 31152740 DOI: 10.1053/j.gastro.2019.05.056] [Citation(s) in RCA: 289] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/18/2019] [Accepted: 05/21/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Proton pump inhibitors (PPIs) are effective at treating acid-related disorders. These drugs are well tolerated in the short term, but long-term treatment was associated with adverse events in observational studies. We aimed to confirm these findings in an adequately powered randomized trial. METHODS We performed a 3 × 2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease randomly assigned to groups given pantoprazole (40 mg daily, n = 8791) or placebo (n = 8807). Participants were also randomly assigned to groups that received rivaroxaban (2.5 mg twice daily) with aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg) alone. We collected data on development of pneumonia, Clostridium difficile infection, other enteric infections, fractures, gastric atrophy, chronic kidney disease, diabetes, chronic obstructive lung disease, dementia, cardiovascular disease, cancer, hospitalizations, and all-cause mortality every 6 months. Patients were followed up for a median of 3.01 years, with 53,152 patient-years of follow-up. RESULTS There was no statistically significant difference between the pantoprazole and placebo groups in safety events except for enteric infections (1.4% vs 1.0% in the placebo group; odds ratio, 1.33; 95% confidence interval, 1.01-1.75). For all other safety outcomes, proportions were similar between groups except for C difficile infection, which was approximately twice as common in the pantoprazole vs the placebo group, although there were only 13 events, so this difference was not statistically significant. CONCLUSIONS In a large placebo-controlled randomized trial, we found that pantoprazole is not associated with any adverse event when used for 3 years, with the possible exception of an increased risk of enteric infections. ClinicalTrials.gov Number: NCT01776424.
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Affiliation(s)
- Paul Moayyedi
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - John W Eikelboom
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jackie Bosch
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Leanne Dyal
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Olga Shestakovska
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Darryl Leong
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sonia S Anand
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Stefan Störk
- University of Würzburg and University Hospital, Würzburg, Germany
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Aldo P Maggioni
- Cardiologists Research Center, Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy
| | - Eva M Lonn
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Georg Ertl
- University of Würzburg and University Hospital, Würzburg, Germany
| | | | | | | | - Gilles R Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | | | | | - P Gabriel Steg
- University Paris Diderot, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Robert G Hart
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rafael Diaz
- Estudios Clinicos Latino America and Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Marco Alings
- Amphia Ziekenhuis and Werkgroep Cardiologische Centra Nederland, Utrecht, The Netherlands
| | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia Sao Paulo, Brazil
| | | | - Jun Zhu
- FuWai Hospital, Beijing, China
| | | | - Patricio Lopez-Jaramillo
- National Association of Hospital Research Institute, Fundaciun Oftalmoligica de Santander-Bucaramanga, Bucaramanga, Colombia
| | - Ajay K Kakkar
- Thrombosis Research Institute and University College London, London, UK
| | | | - Lars Ryden
- Karolinska Institutet, Stockholm, Sweden
| | - Nana Pogosova
- National Research Center for Preventative Medicine, Moscow, Russia
| | | | | | | | | | - Tomek J Guzik
- University of Glasgow, Glasgow, UK; Collegium Medicum Jagiellonian University, Krakow, Poland
| | - Dragos Vinereanu
- University of Medicine and Pharmacology, Carol Davila University and Emergency Hospital, Bucharest, Romania
| | | | | | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo-Universidad Tecnoligica Equinoccial, Quito, Ecuador
| | | | - Kaj P Metsarinne
- Turku University Central Hospital and Turku University, Turku, Finland
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Salim Yusuf
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental. RECENT FINDINGS Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens. SUMMARY Most potential HAP prevention strategies remain unproven.
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75
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Barletta JF, Buckley MS, MacLaren R. The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis? Hosp Pharm 2019; 55:96-101. [PMID: 32214442 DOI: 10.1177/0018578719867687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.
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76
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Shi Y, Huang Y, Zhang TT, Cao B, Wang H, Zhuo C, Ye F, Su X, Fan H, Xu JF, Zhang J, Lai GX, She DY, Zhang XY, He B, He LX, Liu YN, Qu JM. Chinese guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition). J Thorac Dis 2019; 11:2581-2616. [PMID: 31372297 PMCID: PMC6626807 DOI: 10.21037/jtd.2019.06.09] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Shi
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Hui Wang
- Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Fu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Guo-Xiang Lai
- Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China
| | - Dan-Yang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Yan Zhang
- Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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77
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Risk of post-stroke pneumonia with proton pump inhibitors, H2 receptor antagonists and mucoprotective agents: A retrospective nationwide cohort study. PLoS One 2019; 14:e0216750. [PMID: 31067267 PMCID: PMC6505944 DOI: 10.1371/journal.pone.0216750] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/27/2019] [Indexed: 01/16/2023] Open
Abstract
Stroke patients are at high risk of developing pneumonia, which is major cause of post-stroke mortality. Proton pump inhibitors and H2 receptor antagonists are anti-ulcer drugs, which may predispose to the development of pneumonia by suppression of the gastric acid with bactericidal activity. Unlike proton pump inhibitors and H2 receptor antagonists, mucoprotective agents have gastroprotective effects with no or less anti-acid property. We aimed to investigate effects of the acid-suppressive medications (proton pump inhibitors and H2 receptor antagonists) and mucoprotective agents on risk for post-stroke pneumonia using the National Health Insurance Service-National Sample Cohort in Korea. This retrospective cohort study included 8,319 patients with acute ischemic stroke. Use of proton pump inhibitors, H2 receptor antagonists, and mucoprotective agents (rebamipide, teprenone, irsogladine, ecabet, polaprezinc, sofalcone, sucralfate, and misoprostol) after stroke were determined based on the prescription records, which were treated as time-dependent variables. Primary outcome was the development of post-stroke pneumonia. During the mean follow-up period of 3.95 years after stroke, 2,035 (24.5%) patients had pneumonia. In the multivariate time-dependent Cox regression analyses (adjusted hazard ratio [95% confidence interval]), there was significantly increased risk for pneumonia with use of proton pump inhibitors (1.56 [1.24–1.96]) and H2 receptor antagonists (1.40 [1.25–1.58]). In contrast to the proton pump inhibitors and H2 receptor antagonists, use of mucoprotective agents did not significantly increase the risk for pneumonia (0.89 [0.78–1.01]). In conclusion, the treatment with proton pump inhibitors and H2 receptor antagonists was associated with increased risk for pneumonia in stroke patients. Clinicians should use caution in prescribing the acid-suppressive medications for the stroke patients at great risk for pneumonia.
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78
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Lin WL, Muo CS, Lin WC, Hsieh YW, Kao CH. Association of Increased Risk of Pneumonia and Using Proton Pump Inhibitors in Patients With Type II Diabetes Mellitus. Dose Response 2019; 17:1559325819843383. [PMID: 31080379 PMCID: PMC6498779 DOI: 10.1177/1559325819843383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/24/2019] [Accepted: 03/20/2019] [Indexed: 12/15/2022] Open
Abstract
Background: This study explored the possible association between the use of proton pump inhibitors (PPIs) and the increased incidence of pneumonia in patients with type 2 diabetes mellitus (T2DM). Methods: We selected 4940 patients with T2DM of whom 988 and 3952 were enrolled in PPI and propensity score-matched control cohorts, respectively. All patients were followed from the index date until admission with pneumonia, withdrawal from the National Health Insurance program or the end of 2013. The PPIs associated with risk of incident pneumonia were examined. Furthermore, we assessed the risk of pneumonia according to annual defined daily doses in the PPI cohort. Results: After a 14-year follow-up, the cumulative incidence of pneumonia in the PPI users was 11.4% higher than that in the controls (30.3% vs 18.9%). Compared to the controls, the PPI users had a 1.70-fold higher risk of pneumonia in the Cox proportional hazards model after adjustment for matched pairs. The risk of pneumonia increased with the annual PPI defined daily dose. Conclusion: The results of this population-based retrospective cohort study suggest that PPI use increased the risk of pneumonia in patients with T2DM. The effects were more prominent in patients administered higher doses of PPIs.
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Affiliation(s)
- Wen-Ling Lin
- Graduate Institute of Pharmacy, China Medical University, Taichung.,Department of Pharmacy, China Medical University Hospital, Taichung
| | - Chin-Shin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung.,College of Medicine, China Medical University, Taichung
| | - Wen-Chuan Lin
- Graduate Institute of Pharmacy, China Medical University, Taichung
| | - Yow-Wen Hsieh
- Graduate Institute of Pharmacy, China Medical University, Taichung.,Department of Pharmacy, China Medical University Hospital, Taichung
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences and School of Medicine, College of Medicine, China Medical University, Taichung.,Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung.,Department of Bioinformatics and Medical Engineering, Asia University, Taichung
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79
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Marchina S, Doros G, Modak J, Helenius J, Aycock DM, Kumar S. Acid-suppressive medications and risk of pneumonia in acute stroke patients: A systematic review and meta-analysis. J Neurol Sci 2019; 400:122-128. [DOI: 10.1016/j.jns.2019.02.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/20/2018] [Accepted: 02/28/2019] [Indexed: 01/08/2023]
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80
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Dua A, Venu M. Associated risks of proton pump inhibitors and their influence on prescribing habits: is change truly warranted? Dis Esophagus 2019; 32:5212867. [PMID: 30496546 DOI: 10.1093/dote/doy103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- A Dua
- Loyola University Medical Center, Division of Gastroenterology , Stritch School of Medicine, Maywood, Illinois, USA
| | - M Venu
- Loyola University Medical Center, Division of Gastroenterology , Stritch School of Medicine, Maywood, Illinois, USA
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81
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Alshami A, Barona SV, Varon J, Surani S. Gastrointestinal stress ulcer prophylaxis in the intensive care unit, where is the data? World J Meta-Anal 2019; 7:72-76. [DOI: 10.13105/wjma.v7.i3.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. Several strategies for SUP have been suggested over the past four decades, with acid suppressive therapies being the most commonly used in the ICU. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and provision of a simple answer is not feasible at the present time. Recently, a large phase IV, multicenter, randomized clinical trial (SUP-ICU), negated the benefits (and harms) of proton pump inhibitors as SUP. This article reviews some of these controversies.
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Affiliation(s)
- Abbas Alshami
- Dorrington Medical Associates, Houston, TX 77030, United States
- University of Baghdad College of Medicine, Baghdad 12114, Iraq
| | - Sheily Vianney Barona
- Dorrington Medical Associates, Houston, TX 77030, United States
- Benemerita Universidad Autonoma de Puebla, Puebla 72000, Mexico
| | - Joseph Varon
- United General Hospital, 7501 Fanin Street Houston, TX 77054, United States
- Critical Care Services, United Memorial Medical Center, Houston, TX 77091, United States
- Acute and Continuing Care, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
- Medicine, University of Texas Medical Branch at Galveston Houston, Galveston, TX 77555, United States
| | - Salim Surani
- Department of Pulmonary, Critical Care and Sleep Medicine, Texas A&M University, Health Science Center, Bryan, TX 77807, United States
- Pulmonary and Critical Care Fellowship Program, Bay Area Medical Center, Marinette, WI 54143, United States
- Medical Critical Care Services, Christus Spohn Hospitals-Corpus Christi, Corpus Christi, TX 78404, United States
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82
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The multifactorial etiology of stroke-associated pneumonia. J Neurol Sci 2019; 400:30-31. [PMID: 30884370 DOI: 10.1016/j.jns.2019.02.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/23/2022]
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83
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Tang M, Blake KV, Lima JJ, Mougey EB, Franciosi J, Schmidt S, Hossain MJ, Cobbaert M, Fischer BM, Lang JE. Genotype tailored treatment of mild symptomatic acid reflux in children with uncontrolled asthma (GenARA): Rationale and methods. Contemp Clin Trials 2019; 78:27-33. [PMID: 30659924 PMCID: PMC7039713 DOI: 10.1016/j.cct.2019.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/12/2022]
Abstract
Asthma causes enormous suffering and cost for children in the US and around the world [1-3]. Co-morbid gastroesophageal reflux disease (GERD) makes asthma management more difficult due to increased symptoms. Proton pump inhibitor (PPI) drugs are effective at improving to GERD symptoms, however they have demonstrated only modest and variable effects on asthma control in the setting of co-morbid GERD. Importantly, PPI metabolism and efficacy depend on CYP2C19 genotype. The Genotype Tailored Treatment of Symptomatic Acid Reflux in Children with Uncontrolled Asthma (GenARA) study is a randomized, double-blind, placebo-controlled trial to determine if genotype-tailored PPI dosing improves asthma symptoms among children with inadequately controlled asthma and GERD symptoms. This study has an innovative design to both assess the efficacy of genotype-tailored PPI dosing and perform pharmacokinetic modeling of the oral PPI Lansoprazole. Children ages 6-17 years old with clinician-diagnosed asthma and mild GERD symptoms will submit a saliva sample for CYP2C19 genotyping. Participants will undergo a two-step randomization to: (1) genotype-tailored versus conventional dosing of open-label oral lansoprazole for pharmacokinetic modeling, and (2) genotype-tailored lansoprazole daily versus placebo for 24 weeks to determine the effect of genotype-tailored PPI dosing on asthma control. Measures of asthma control, spirometry, and nasal washes during acute illnesses will be collected at 8-week intervals throughout the study. GenARA will better define the effects of CYP2C19 genotype on the dose response of lansoprazole in children and adolescents and assess if a novel dosing regimen improves GERD and asthma control.
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Affiliation(s)
- Monica Tang
- Division of Allergy/Immunology and Pulmonary Medicine, Duke University School of Medicine, Duke Children's Hospital and Health Center, Durham, NC, United States
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, United States
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, United States
| | - Edward B Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, United States
| | - James Franciosi
- Department of Pediatrics, Nemours Children's Hospital, Nemours Children's Health System, Orlando, FL, United States
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, United States
| | - Md Jobayer Hossain
- Department of Biomedical Research, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, United States
| | - Marjan Cobbaert
- Department of Pharmacometrics, Duke Clinical Research Institute, Durham, NC, United States
| | - Bernard M Fischer
- Division of Allergy/Immunology and Pulmonary Medicine, Duke University School of Medicine, Duke Children's Hospital and Health Center, Durham, NC, United States
| | - Jason E Lang
- Division of Allergy/Immunology and Pulmonary Medicine, Duke University School of Medicine, Duke Children's Hospital and Health Center, Durham, NC, United States.
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84
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Liao S, Gan L, Mei Z. Does the use of proton pump inhibitors increase the risk of hypomagnesemia: An updated systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15011. [PMID: 30921222 PMCID: PMC6456119 DOI: 10.1097/md.0000000000015011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly used in the treatment of acid-related diseases; however, the association between the use of PPIs and potential risk of hypomagnesemia is controversial. METHODS In the present study, databases including PubMed, EMBASE, MEDLINE, PsycINFO, CINAHL, the Cochrane Library, and 4 Chinese databases were searched since the inception until April 2018. Previous observational studies on the incidence of hypomagnesemia in individuals exposed to PPIs were included. RESULTS This systematic review involved 15 studies including 129,347 participants, and the sample size varied from 52 to 95,205. Meta-analysis of 14 studies indicated that the use of PPIs increased the risk of hypomagnesemia [RR, 1.44, 95% CI, 1.13-1.76; I, 85.2%]. Subgroup analysis revealed that the use of PPI was not associated with the incidence of hypomagnesemia in outpatients [RR, 1.49; 95% CI, 0.83-2.14; I, 41.4%] and hospitalized patients [RR, 1.05; 95% CI, 0.81-1.29; I, 62.1%], respectively. The use of PPIs was not related to the risk of hypomagnesemia based on the cut-off values of 1.8 mg/dL [RR, 1.73; 95% CI, 0.87-2.58; I, 65.2%], 1.7 mg/dL [RR, 1.48; 95% CI, 0.90-2.06; I, 87.6%], and 1.6 mg/dL [RR, 0.98; 95% CI, 0.69-1.27; I, 67.9%]. CONCLUSION The association between the exposure to PPI and the incidence of hypomagnesemia remained unclear. Due to the remarkable heterogeneity in previous studies, a definitive conclusion could not be drawn. Further research should be conducted to investigate the relationship between the use of individual PPI and potential risk of hypomagnesemia, and a dose-response analysis may be required.
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Affiliation(s)
- Shengtao Liao
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Li Gan
- Department of Anatomy, North Sichuan Medical College, Nanchong, Sichuan, P.R. China
| | - Zhechuan Mei
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing
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85
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Dwivedi S, Edukulla J, Rajendra S, Murali S, Sorser SA, Piper MS, Piper M, Warren BJ, Ramchandani H. Educational intervention can improve appropriateness of acid suppression therapy in hospitalized geriatric patients. J Community Hosp Intern Med Perspect 2019; 9:5-8. [PMID: 30788067 PMCID: PMC6374937 DOI: 10.1080/20009666.2019.1571881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/08/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Inappropriate use of acid suppression (AST) therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, AST remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess its prevalence and create educational intervention to improve the appropriateness of inpatient acid suppression therapy. Methods: Using a time-series design, we established a historical control by performing a retrospective chart. Accepted indications for AST were based on those endorsed by the USA Food and Drug Administration and literature review. Inclusion criteria were: (1) age ≥ 65; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data was collected for two months after the intervention. We used a two-tail fisher exact test and student’s t-test to analyze our results. Results: 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < 0.05). Conclusion: There is a significant overuse of AST in hospitalized geriatric patients. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.
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Affiliation(s)
- Sankalp Dwivedi
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Jaya Edukulla
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Sindhu Rajendra
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Navicent Health Baldwin, Milledgeville, GA, USA
| | - Sandesh Murali
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Navicent Health Baldwin, Milledgeville, GA, USA
| | - Serge A Sorser
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Marc S Piper
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Michael Piper
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Bradley J Warren
- Department of Gastroenterology, Providence - Providence Park Hospital, Michigan State University, Southfield, MI, USA
| | - Harsha Ramchandani
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA.,Department of Internal Medicine, Tricity Health Center, Fremont, CA, USA
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86
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Wang CH, Li CH, Hsieh R, Fan CY, Hsu TC, Chang WC, Hsu WT, Lin YY, Lee CC. Proton pump inhibitors therapy and the risk of pneumonia: a systematic review and meta‐analysis of randomized controlled trials and observational studies. Expert Opin Drug Saf 2019; 18:163-172. [DOI: 10.1080/14740338.2019.1577820] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Han Li
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ronan Hsieh
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Cheng-Yi Fan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tze-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Che Chang
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Yu-Ya Lin
- Department of Pharmacy, E-Da hospital, Kaohsiung, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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87
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Chang AB, Redding GJ. Bronchiectasis and Chronic Suppurative Lung Disease. KENDIG'S DISORDERS OF THE RESPIRATORY TRACT IN CHILDREN 2019. [PMCID: PMC7161398 DOI: 10.1016/b978-0-323-44887-1.00026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
By nearly any criteria, pneumonia (infection of the pulmonary parenchyma) must be considered one of the most important categories of disease affecting the respiratory system. This chapter is organized primarily as a general discussion of the clinical problem of pneumonia. As appropriate, the focus on individual etiologic agents highlights some characteristic features of each that are particularly useful to the physician. Also covered is a commonly used categorization of pneumonia based on the clinical setting: community-acquired versus nosocomial (hospital-acquired) pneumonia. In current clinical practice, the approach to evaluation and management of these two types of pneumonia is often quite different. The chapter concludes with a brief discussion of several infections that were uncommon or primarily of historical interest until recently, as the threat of bioterrorism emerged. In addition to reviewing inhalational anthrax, the chapter briefly describes two other organisms considered to be of concern as potential weapons of bioterrorism: Yersinia pestis (the cause of plague) and Francisella tularensis (the cause of tularemia).
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89
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Jaynes M, Kumar AB. The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf 2018; 10:2042098618809927. [PMID: 31019676 PMCID: PMC6463334 DOI: 10.1177/2042098618809927] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022] Open
Abstract
Proton pump inhibitors (PPIs) are among the most frequently prescribed
medications. Their use is likely even higher than estimated due to an increase
in the number of PPIs available without a prescription. Appropriate indications
for PPI use include Helicobacter pylori infection, erosive
esophagitis, gastric ulcers, and stress ulcer prevention in high-risk critically
ill patients. Unfortunately, PPIs are often used off-label for extended periods
of time. This increase in PPI usage over the past two decades has called into
question the long-term effects of these medications. The association between PPI
use and infection, particularly Clostridium difficile and
pneumonia, has been the subject of several studies. It’s proposed that
the alteration in gastrointestinal microflora by PPIs produces an environment
conducive to development of these types of infections. At least one study has
suggested that long-term PPI use increases the risk of dementia. Drug
interactions are an important and often overlooked consideration when
prescribing any medication. The potential interaction between PPIs and
antiplatelet agents has been the subject of multiple studies. One of the more
recent concerns with PPI use is their role in the development or progression of
chronic kidney disease. There is also some literature suggesting that PPIs
contribute to the development of various micronutrient deficiencies. Most of the
literature examining the potential adverse effects of PPI use is composed of
retrospective, observation studies. There is a need for higher quality studies
exploring this relationship.
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Affiliation(s)
- Megan Jaynes
- Division of Critical Care, Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Avinash B Kumar
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, TN 37212, USA
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90
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Bacteriologic Evaluation of Ventilator-Associated Pneumonia According to Stress Related Mucosal Disease Prophylaxis in the Intensive Care Unit. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2018. [DOI: 10.5812/archcid.82521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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91
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Costa P, Almeida MO, Lemos M, Arruda C, Casoti R, Somensi LB, Boeing T, Mariott M, da Silva RDCMVDAF, Stein BDP, Souza PD, Dos Santos AC, Bastos JK, da Silva LM, Andrade SFD. Artepillin C, drupanin, aromadendrin-4'-O-methyl-ether and kaempferide from Brazilian green propolis promote gastroprotective action by diversified mode of action. JOURNAL OF ETHNOPHARMACOLOGY 2018; 226:82-89. [PMID: 30107246 DOI: 10.1016/j.jep.2018.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/29/2018] [Accepted: 08/09/2018] [Indexed: 06/08/2023]
Abstract
ETHOPHARMACOLOGICAL RELEVANCE The propolis is extensively used in folk medicine in natura or to prepare pharmaceutical formulations since ancient time to improve health or prevent diseases, among them gastrointestinal disorders. Aiming to contribute in the scientific validation about the popular use of Brazilian Green propolis (BGP) against gastritis and gastric ulcer, this work evaluated the antiulcer potential of isolated compounds from BGP, three prenylated p-coumaric acid derivatives and two flavonoids, respectively named: 3,5 diprenyl-4-hydroxycinnamic acid (artepillin C) (1), 3-prenyl-4-dihydroxycinnamoiloxy cinnamic acid (baccharin) (2), 3-prenyl-4-hydroxycinnamic acid (drupanin) (3), aromadendrin-4'-O-methyl-ether (4) and kaempferide (5). MATERIAL AND METHODS The compounds were characterized by nuclear magnetic resonance and mass spectrometry. Their gastroprotective effects were evaluated against ethanol/HCl- and indomethacin-induced ulcer in mice. Further, histological, histochemical, oxidative and inflammatory parameters were analyzed at ulcerated tissue. Acid antisecretory activities also were also assessed. RESULTS Compound 2 did not reduce the ethanol/HCl- induced ulcer at 30 mg/kg (p.o), whereas the minimum oral gastroprotective doses of 1, 3, 4 and 5 were 0.3, 0.3, 3 and 3 mg/kg, respectively. Besides, these compounds prevented ethanol/HCl-induced ulcer by intraperitoneal route, as well as indomethacin-induced ulcer by oral route. The gastroprotection was accompanied by normalization of superoxide dismutase, catalase and glutathione-S-transferase activities and reduction in myeloperoxidase activity. Moreover, the compounds 4 and 5 increased the gastric mucin content and 1 reduced TNF amount. Furthermore, 1, 3, 4 and 5 decreased volume, pH, total acidity and pepsin activity of the gastric juice from rats. CONCLUSIONS Together, our findings showed a diversified mode of action elicited by 1, 3, 4 and 5 on the gastroprotection and contribute to explain the anti-ulcer activity reported for BGP.
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Affiliation(s)
- Philipe Costa
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Marilia O Almeida
- School of Pharmaceutical Sciences of Ribeirão Preto of the University of São Paulo, Avenida do Café, s/n, 14040-903 Ribeirão Preto, SP, Brazil
| | - Marivane Lemos
- School of Pharmaceutical Sciences of Ribeirão Preto of the University of São Paulo, Avenida do Café, s/n, 14040-903 Ribeirão Preto, SP, Brazil
| | - Caroline Arruda
- School of Pharmaceutical Sciences of Ribeirão Preto of the University of São Paulo, Avenida do Café, s/n, 14040-903 Ribeirão Preto, SP, Brazil
| | - Rosana Casoti
- School of Pharmaceutical Sciences of Ribeirão Preto of the University of São Paulo, Avenida do Café, s/n, 14040-903 Ribeirão Preto, SP, Brazil
| | - Lincon Bordignon Somensi
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Thaise Boeing
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Marihá Mariott
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Rita de Cássia Melo Vilhena de Andrade Fonseca da Silva
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Bruna De Paoli Stein
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Priscila de Souza
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Ana Caroline Dos Santos
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Jairo K Bastos
- School of Pharmaceutical Sciences of Ribeirão Preto of the University of São Paulo, Avenida do Café, s/n, 14040-903 Ribeirão Preto, SP, Brazil
| | - Luísa Mota da Silva
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil
| | - Sérgio Faloni de Andrade
- Programa de Pós Graduação em Ciências Farmacêuticas, Núcleo de Investigações Químico-Farmacêuticas (NIQFAR), Universidade do Vale do Itajai (UNIVALI) - Campus Itajaí, Rua Uruguai, 458, Centro CEP: 88302-901, Santa Catarina, Brazil.
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Costabel U, Behr J, Crestani B, Stansen W, Schlenker-Herceg R, Stowasser S, Raghu G. Anti-acid therapy in idiopathic pulmonary fibrosis: insights from the INPULSIS® trials. Respir Res 2018; 19:167. [PMID: 30176872 PMCID: PMC6122773 DOI: 10.1186/s12931-018-0866-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/20/2018] [Indexed: 01/20/2023] Open
Abstract
Background The benefits and risks of anti-acid medication in patients with idiopathic pulmonary fibrosis (IPF) remain a topic of debate. We investigated whether use of anti-acid medication at baseline was associated with differences in the natural course of disease or influenced the treatment effect of nintedanib in patients with IPF. Methods Post-hoc analyses of outcomes in patients receiving versus not receiving anti-acid medication (proton pump or histamine-2 receptor inhibitor) at baseline using pooled data from the two Phase III randomized placebo-controlled INPULSIS® trials of nintedanib in patients with IPF. Results At baseline, 406 patients were receiving anti-acid medication (244 nintedanib; 162 placebo) and 655 were not (394 nintedanib; 261 placebo). In an analysis of the natural course of IPF by anti-acid medication use at baseline, the adjusted annual rate of decline in FVC was − 252.9 mL/year in placebo-treated patients who were receiving anti-acid medication at baseline and − 205.4 mL/year in placebo-treated patients who were not (difference of − 47.5 mL/year [95% CI: –105.1, 10.1]; p = 0.1057). In an analysis of the potential influence of anti-acid medication use on the treatment effect of nintedanib, the adjusted annual rates of decline in FVC were − 124.4 mL/year in the nintedanib group and − 252.9 mL/year in the placebo group (difference of 128.6 mL/year [95% CI: 74.9, 182.2]) in patients who were receiving anti-acid medication at baseline and − 107.0 mL/year in the nintedanib group and − 205.3 mL/year in the placebo group (difference of 98.3 mL/year [95% CI: 54.1, 142.5]) in patients who were not (treatment-by-time-by-subgroup interaction p = 0.3869). The proportions of patients who had ≥1 investigator-reported acute exacerbation were 11.7% and 5.0% in placebo-treated patients, and 4.9% and 4.8% of nintedanib-treated patients, among patients who were and were not receiving anti-acid medication at baseline, respectively. Conclusions In post-hoc analyses of data from the INPULSIS® trials, anti-acid medication use at baseline was not associated with a more favorable course of disease, and did not impact the treatment effect of nintedanib, in patients with IPF. Trial registration ClinicalTrials.gov identifiers: NCT01335464 and NCT01335477. Electronic supplementary material The online version of this article (10.1186/s12931-018-0866-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulrich Costabel
- Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, University of Munich (LMU) and Asklepios Klinik München-Gauting, Member of the German Center for Lung Research, Munich, Germany
| | - Bruno Crestani
- APHP, Hôpital Bichat, Service de Pneumologie A, DHU FIRE; INSERM, Unité 1152; Université Paris Diderot, Paris, France
| | - Wibke Stansen
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
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Doell A, Walus A, To J, Bell A. Quantifying Candidacy for Deprescribing of Proton Pump Inhibitors among Long-Term Care Residents. Can J Hosp Pharm 2018; 71:302-307. [PMID: 30401996 PMCID: PMC6209507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are a commonly prescribed drug class used to inhibit gastric acid secretion. They are prescribed for both treatment and prophylaxis of several gastrointestinal conditions. Although PPIs can be used safely in the short term, several serious adverse effects have been reported following long-term use, including increased risk of falls and fragility fractures. Long-term care home (LTCH) residents represent a population in which the long-term adverse effects of PPIs can be significant and PPI deprescribing should be considered when appropriate. OBJECTIVES To determine the proportion of LTCH residents with PPI prescriptions who were eligible for PPI deprescribing, and to examine vitamin B12 deficiencies and fall risk in the study population. METHODS This cross-sectional, multisite chart review involved LTCH residents who had an active PPI prescription during October 2016. A convenience sample of 150 charts was randomly selected, and the appropriateness of PPI deprescribing was determined using Canadian guidelines. Descriptive statistics were used to examine demographic characteristics, PPI dosing and indication, vitamin B12 supplementation, fall history, and fall risk. RESULTS Three of the selected charts were excluded because of missing information. Of the 147 residents included in the chart review, 93 (63%) were candidates for deprescribing. PPI use for gastroesophageal reflux disease for more than 8 weeks without a deprescribing attempt in the past year was the most frequently observed opportunity for deprescribing (49/93 [53%]). Twenty-nine residents (20%) had no documented indication for PPI use. Thirteen residents (9%) had had a fall within the past 30 days, and 53 (36%) had a prescription for vitamin B12 supplements and/or had low serum vitamin B12 levels. CONCLUSIONS A majority of the residents whose charts were reviewed were candidates for PPI deprescribing. This finding suggests an opportunity for clinicians who care for LTCH residents to increase their deprescribing efforts.
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Affiliation(s)
- Alanna Doell
- , BScPharm, ACPR, is a Staff Pharmacist with Seven Oaks General Hospital of the Winnipeg Regional Health Authority, Winnipeg, Manitoba
| | - Ashley Walus
- , BScPharm, ACPR, is a Clinical Resource Pharmacist with the Winnipeg Regional Health Authority, Winnipeg, Manitoba
| | - Jaclyn To
- , BScPharm, ACPR, is a Staff Pharmacist with the Victoria General Hospital of the Winnipeg Regional Health Authority, Winnipeg, Manitoba
| | - Allison Bell
- , BScPharm, is the Pharmacy Manager with the Long Term Care Program of the Winnipeg Regional Health Authority, Winnipeg, Manitoba
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94
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Robinson LB, Camargo CA. Acid suppressant medications and the risk of allergic diseases. Expert Rev Clin Immunol 2018; 14:771-780. [PMID: 30113236 PMCID: PMC6332498 DOI: 10.1080/1744666x.2018.1512405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acid suppressant medications (ASMs), such as proton pump inhibitors and histamine-2 receptor antagonists, are used often and throughout the lifespan. These medications have been linked to the development of a variety of allergic diseases. Areas covered: This review discusses prior studies investigating the association between acid ASM exposure and the development of allergic diseases. We performed a thorough literature search to identify potentially relevant studies for inclusion. In summary, exposure to these medications prenatally, in childhood and in adulthood, may increase the risk of allergic diseases. The current evidence is limited by primarily observational study design and potential bias and confounding. The mechanism of action is not yet known, but there are several proposed theories. Expert commentary: There is a growing body of evidence to support that exposure to acid ASMs increases the risk of developing allergic diseases. Further research is needed to not only clarify this relationship but to define the potential mechanism of action. If further research confirms these observations, we believe that could warrant changes in the patterns of prescribing and use of acid ASMs.
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Affiliation(s)
- Lacey B. Robinson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Cox 201 Boston MA 02114, USA.
| | - Carlos A. Camargo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Cox 201 Boston MA 02114, USA.
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston MA 02114, USA.
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95
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Saad EJ, Bedini M, Becerra AF, Martini GD, Gonzalez JG, Bolomo A, Castellani L, Quiroga S, Morales C, Leathers J, Balderramo D, Albertini RA. Benefit of an electronic medical record-based alarm in the optimization of stress ulcer prophylaxis. GASTROENTEROLOGÍA Y HEPATOLOGÍA (ENGLISH EDITION) 2018; 41:432-439. [DOI: 10.1016/j.gastre.2018.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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96
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Gao F, Méndez-Sánchez N, Qi X. Vasoconstrictors in combination with proton pump inhibitors as an initial treatment of acute upper gastrointestinal bleeding in liver cirrhosis: is it evidence based? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:327. [PMID: 30363965 PMCID: PMC6186974 DOI: 10.21037/atm.2018.08.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/07/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Fan Gao
- Medical Department, No. 202 Hospital of Chinese PLA, Shenyang 110003, China
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
| | | | - Xingshun Qi
- Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110840, China
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97
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Saad EJ, Bedini M, Becerra AF, Martini GD, Gonzalez JG, Bolomo A, Castellani L, Quiroga S, Morales C, Leathers J, Balderramo D, Albertini RA. Benefit of an electronic medical record-based alarm in the optimization of stress ulcer prophylaxis. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:432-439. [DOI: 10.1016/j.gastrohep.2018.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 01/27/2023]
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98
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Tranberg A, Thorarinsdottir HR, Holmberg A, Schött U, Klarin B. Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx. Acta Anaesthesiol Scand 2018. [PMID: 29520757 DOI: 10.1111/aas.13094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The normal body exists in mutualistic balance with a large range of microbiota. The primary goal of this study was to establish whether there is an imbalance in the oropharyngeal flora early after hospital or ICU admittance, and whether flora differs between control, ward and critically ill patients. The secondary goal was to explore whether there are patient characteristics that can be associated with a disturbed oropharyngeal flora. METHODS Oropharyngeal cultures were obtained from three different study groups: (1) controls from the community, (2) ward patients and (3) critically ill patients, the two latter within 24 h after admittance. RESULTS Cultures were obtained from 487 individuals: 77 controls, 193 ward patients and 217 critically ill patients. Abnormal pharyngeal flora was more frequent in critically ill and ward patients compared with controls (62.2% and 10.4% vs. 1.3%, P < 0.001 and P = 0.010, respectively). Colonisation of gut flora in the oropharynx was more frequent in critically ill patients compared with ward patients or controls (26.3% vs. 4.7% and 1.3%, P < 0.001 and P < 0.001, respectively). Proton pump inhibitor medication was the strongest independent factor associated with the presence of gut flora in the oropharynx in both ward and critically ill patients (P = 0.030 and P = 0.044, respectively). CONCLUSION This study indicates that abnormal oropharyngeal flora is an early and frequent event in hospitalised patients and more so in the critically ill, compared to controls. Proton pump inhibitor medication is associated with colonisation of gut flora in the oropharynx.
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Affiliation(s)
- A. Tranberg
- Division of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
| | - H. R. Thorarinsdottir
- Division of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
| | - A. Holmberg
- Division of Infection Medicine; Department of Clinical Sciences; Lund University; Lund Sweden
| | - U. Schött
- Division of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
| | - B. Klarin
- Division of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
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Affiliation(s)
- Deborah Cook
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Lioutas VA, Marchina S, Caplan LR, Selim M, Tarsia J, Catanese L, Edlow J, Kumar S. Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage. Cerebrovasc Dis 2018; 45:270-278. [PMID: 29898436 DOI: 10.1159/000489273] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/15/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for "airway protection" with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated. METHODS We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders. RESULTS Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48-7.22; p < 0.0001) and 4.32 (95% CI 2.5-7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively. CONCLUSION In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Marchina
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Louis R Caplan
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Magdy Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Tarsia
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Luciana Catanese
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Edlow
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sandeep Kumar
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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