Events In Medical Patients Research Articles

ECT for Depression May Cut Suicide Risk by Nearly 50%

Back to table of contents Previous article Next article Clinical & ResearchFull AccessECT for Depression May Cut Suicide Risk by Nearly 50%Nick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:22 Aug 2022https://doi.org/10.1176/appi.pn.2022.09.7.20AbstractThe study also found that suicide risk reduction was more pronounced in patients with unipolar depression than in patients with bipolar depression.Patients hospitalized for depression who received electroconvulsive therapy (ECT) had a nearly 50% reduced risk of suicide death over the following year versus comparable patients who did not receive ECT. The findings came from a detailed analysis of over 67,000 hospital records from patients seen in psychiatric inpatient units across Ontario, Canada.The analysis, published in Lancet Psychiatry, also found that patients who received ECT were less likely to die from other causes within one year after discharge.The findings provide further evidence that ECT can be a lifesaving treatment for patients with severe depression, said lead author Tyler Kaster, M.D., Ph.D., an assistant professor of psychiatry at the University of Toronto and medical head at the Temerty Centre for Therapeutic Brain Intervention.Kaster and colleagues used Canadian registries to examine the 12-month mortality outcomes of all adults aged 18 and older in Ontario who spent more than three days hospitalized for unipolar or bipolar depression between April 1, 2007, and December 31, 2017. Individuals were included in the analysis multiple times if their hospitalizations occurred more than 12 months apart. The final sample included 67,327 hospital admissions, during which 4,982 patients received ECT.A total of 450 deaths from suicide occurred within 12 months of discharge from the hospital; this included the deaths of 27 people who received ECT (5.84 per 1,000 person-years) and 423 who did not receive ECT (7.26 per 1,000 person-years).After adjusting for more than 100 demographic and medical variables that might influence whether a hospitalized patient would be a good candidate for ECT (such as age, psychotic symptoms, and physical comorbidities), the researchers found that patients who received ECT in the hospital had a 47% reduced risk of suicide death and a 25% reduced risk of any death over 12 months compared with those who did not receive ECT. Additional analysis revealed that suicide risk reduction was more pronounced in patients with unipolar depression than in patients with bipolar depression.Kaster and colleagues estimated that for every 200 hospitalized patients treated with ECT, one suicide will be prevented, which is about the same benefit seen with lithium treatment among people with bipolar disorder. Kaster said that while the number of suicides prevented by ECT may appear low, it is meaningful as suicide is a very rare event.Kaster noted that previous research he conducted also found no evidence that patients hospitalized for depression who received ECT were at an increased risk of serious medical events, compared with patients who did not receive ECT.While ECT is not for every depressed patient, Kaster said he hoped that the medical event and mortality data would provide further support that ECT is a medically safe procedure.“[ECT] is still the most invasive treatment for depression we have and any decision to proceed has to be made very thoughtfully, weighing all the benefits and risks,” he said.This study was supported by the Canadian Institutes for Health Research, Norris Scholars Award, and University of Toronto. ■Resources“Risk of Suicide Death Following Electroconvulsive Therapy Treatment for Depression: a Propensity Score-Weighted, Retrospective Cohort Study in Canada”“Risk of Serious Medical Events in Patients With Depression Treated With Electroconvulsive Therapy: A Propensity Score-Matched Retrospective Cohort Study” ISSUES NewArchived

Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study

Previous studies examining the risk of medical complications from electroconvulsive therapy have been confounded and this might contribute to its underuse. This study aimed to compare the risk of serious medical events, defined as those resulting in hospitalisation or death, among patients with depression who received electroconvulsive therapy versus patients who did not receive electroconvulsive therapy. This was a propensity score-matched, retrospective cohort study using linked population-based administrative health data for adults admitted to designated psychiatric facilities in Ontario, Canada, for more than 3 days with depression between April 1, 2007, to Feb 28, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The unit of analysis was individual admissions and propensity score matching was used to match each exposed admission to an unexposed admission to estimate the average treatment effect of electroconvulsive therapy among those treated. The primary outcome was serious medical events, a composite of hospitalisation for medical (ie, non-psychiatric) reasons or non-suicide death within 30 days from electroconvulsive therapy exposure or matched date in the unexposed group. Effect modification was examined using tests of interaction for three clinically relevant prespecified subgroups (sex, presence of psychotic symptoms, and illness polarity). Secondary outcomes were medical hospitalisation and non-suicide death separately, suicide death, and specific serious medical events. In propensity score matched analyses, there were 10 016 psychiatric hospitalisation records (6628 women, 3388 men) with mean age 56·6 years (SD 16·3) and no ethnicity data available. 65 818 admissions were eligible for matching and 5008 were matched (1:1) in each exposure group. In the propensity score matched cohort, the incidence of serious medical events was 0·25 per person-year in the exposed group and 0·33 per person-year in the unexposed group (cause-specific hazard ratio 0·78 [95% CI 0·61-1·00]). Suicide death as a competing risk did not alter this finding. The risk of suicide death was significantly lower in the exposed (≤5 of 5008 admissions) versus the unexposed group (11 [0·2%] of 5008 admissions; p<0·03). Bipolar depression, compared with unipolar depression, was associated with a greater reduction in the risk of serious medical events with electroconvulsive therapy. Electroconvulsive therapy was not associated with medical hospitalisation or non-suicide death separately, nor with any specific serious medical event. Among individuals hospitalised with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population. Norris Scholars Award, Department of Psychiatry, University of Toronto; the Canadian Institutes for Health Research.

Modified glasgow prognostic score predicts perioperative adverse events in elderly patients undergoing hip fracture surgery

Aim: The association between modified Glasgow prognostic score (mGPS) and prognosis in patients undergoing hip fracture surgery (HFS) has not been studied. Therefore, we aimed to evaluate the predictive value of mGPS in outcomes of patients undergoing HFS..Material and Methods: A total of 301 adult patients aged ≥ 65 years, undergoing HFS were included in this retrospective study. The mGPS was scored according to C-reactive protein (CRP) and albumin levels at enrolment. Patients with both elevated CRP (>1 mg/dL) and hypoalbuminemia (3.5 g/dL) are given mGPS of 2, patients with serum CRP ≤ 1 g/dL with or without hypoalbuminemia received scores of 0. Patients with only elevated CRP levels received mGPS of 1. Primary outcome of the study was major perioperative adverse medical events defined as cardiovascular and noncardiovascular complications.Results: A total of 38 patients (12.6%) experienced perioperative adverse medical events. Compared to patients without perioperative complications, patients with adverse events were more likely to have higher mGPS levels prior to surgert. Multivariate analysis showed that higher mGPS at presentation was an independent predictor of perioperative adverse medical events in patients undergoing HFS. Conclusion: This is the first study which demonstrates that mGPS is a predictor of adverse events in patients with undergoing HFS.

Increased diabetes risk and interaction with social and medical events in patients upon stroke: Two nationwide studies

Background & aimsThe relationship between stroke and diabetes is not completely understood. This study evaluated diabetes risk and post-diabetes adverse events in patients with stroke. MethodsWe identified 10,255 adults, newly diagnosed with stroke from 2000 to 2005, using the Taiwan's National Health Insurance Research Database. A comparison cohort of 41,020 adults without stroke was randomly selected from the same dataset, frequency matched by age and sex. Diabetes events from 2000 to 2013 were ascertained from medical claims. Adjusted hazard ratios (HRs) and 95% CIs were calculated for diabetes associated with stroke. A nested cohort study of 33,437 patients with inpatient care for diabetes between 2008 and 2013 was conducted to calculate the adjusted odds ratios (ORs) and 95% CIs for adverse events after diabetes, in patients with and without stroke. ResultsDuring 489,561 person-years of follow-up, there were 10,742 newly diagnosed diabetes cases. The incidence of diabetes for people with and without stroke was 43.9 and 17.8 per 1000 person-years, respectively (p < 0.0001). Compared to that for people without stroke, the adjusted HR for diabetes was 2.69 (95% CI 2.56–2.82) for stroke patients. The ORs of post-diabetes pneumonia, urinary tract infection, and mortality associated with stroke were 1.35 (95% CI 1.17–1.55), 1.52 (95% CI 1.36–1.70), and 1.71 (95% CI 1.27–2.29), respectively. ConclusionsWe provide evidence that the consequences of stroke are not limited to the neurological defect, but evoke diabetes and a plethora of associated medical, psychological and social impacts the physician must be strongly aware of if evaluating and treating stroke patients.

Evaluation of an oral direct anti-Xa anticoagulant, apixaban, for the prevention of venous thromboembolism in patients with myeloma treated with IMiD* compounds: A pilot study (MYELAXAT).

8019 Background: The risk of venous thromboembolism (VTE) is higher in myeloma patients recieving IMiD* compounds (IMiD*: registered). A VTE prophylaxis using low-molecular-weight heparin or aspirin is proposed. Apixaban is an oral direct anti-Xa. Several studies have shown the efficiency and safety of apixaban in VTE prophylaxis compared to enoxaparin. The objective of this prospective pilot study was to assess the risk of VTE and bleeding in patients with myeloma treated with IMiD* compounds, using apixaban in a preventive scheme. Methods: Myeloma patients requiring Melphalan-Prednisone-Thalidomide in first line, or Lenalidomide-Dexamethasone in relapse, asymptomatic regarding VTE at inclusion, were enrolled between 2014 - 2016. All patients recieved apixaban, 2.5 mg x 2/day for 6 months, and were monthly monitored. Venous (pulmonary embolism – PE, or symptomatic proximal or distal deep vein thrombosis - DVT, or all proximal asymptomatic events detected by systematic proximal bilateral compression ultrasound) or arterial thrombotic events, and bleeding events (ISTH 2005) were registered. Based on meta-analysis of Carrier regarding VTE recurrence, and results from the ADOPT study in medical conditions regarding hemorrhages, &lt; 13 symptomatic VTE events, &lt; 3 severe and &lt; 14 clinically relevant non major (CRNM) bleeding were expected on the treatment period. Results: 104 patients were enrolled (mean age 69.8 +/- 7.8yrs), 11 in first line, 93 in relapse. No PE or arterial cardiovascular events were reported. Two venous thrombotic events were registered, i.e an asymptomatic proximal DVT (patient in relapse) and a symptomatic distal DVT, although apixaban was stopped 14 days before, due to Lenalidomide-induced thrombopenia. Only one major and 11 CRNM hemorrhages were reported. Conclusions: Referring to the incidence of thromboembolic events in Carrier’s meta-analysis, and to hemorrhagic events in medical patients recieving apixaban in primary VTE prophylaxis, apixaban used in a preventive scheme seems to be efficient and safe in preventing VTE in myeloma patients treated with IMiD* compounds. Clinical trial information: NCT02066454.

The impact of a nurse led rapid response system on adverse, major adverse events and activation of the medical emergency team

To identify the relationship between one example of a rapid response system (RRS), specifically, an after-hours Clinical Team Co-Ordinator (CTC), and the incidence of Medical Emergency Team (MET) activations and, adverse and major adverse events in medical patients. A retrospective chart audit of patients' medical records was undertaken. The intervention group consisted of 150 randomly selected medical patients admitted during three months after the introduction of the CTC after-hours service. The control group consisted of 150 randomly selected medical patients admitted before the introduction of the after-hours CTC service. Multiple logistic regression was used to determine which of the potential predictors, along with the after-hours CTC service, were associated with adverse and major adverse events. A total of 130 patients (n=63, 42% control; n=67, 45% intervention) exhibited physiological abnormalities that should have activated the MET yet it was only activated five times. In total there were 69 adverse events (n=32, 21% control; n=36, 25% intervention) and 25 major adverse events (n=7, 5% control; n=18, 12% intervention). There were more adverse and major adverse events identified after the introduction of the CTC after-hours service. Changes in heart rate and reduction in Glasgow Coma Scores (GCS) were significant predictors of an adverse event. A low urine output and a drop of two or more in the GCS were significant predictors of a major adverse event. The introduction of an after-hours CTC service in a specific clinical site was associated with an increase in the identification of adverse and major adverse events in medical patients. Further exploration of nurse-led rapid response systems should be undertaken in different clinical settings.

Eligibility for medical thromboprophylaxis based on risk‐factor weights, and clinical thrombotic event rates

To measure eligibility for medical thromboprophylaxis using two Australasian guidelines - the Australia and New Zealand Working Party Guidelines [WPG] and the National Health and Medical Research Council Guidelines [NHMRCG]) - and proposed new guidelines based on risk-factor weights; and to measure the incidence of clinical venous thromboembolism (VTE) events in medical patients ("ensuing VTE"). Prospective case-note audit in an acute medical ward of Southland Hospital, a regional hospital in Invercargill, New Zealand, among all 595 patients who were discharged consecutively from 21 November 2010 to 7 March 2011. Of these, 245 were excluded on clinical grounds or because they were under the care of the authors. The primary outcome was eligibility for prophylaxis under each guideline. Secondary outcomes included incidence of ensuing VTEs, use of thromboprophylaxis, drug acquisition costs with each guideline, and bedside practicability of a guideline based on risk-factor weights. Nineteen per cent of patients were eligible under the new guidelines, compared with 80%, 88% and 36% under the WPG and two interpetations of the NHMRCG, respectively. One patient had an ensuing VTE. The new guideline had lower drug acquisition costs and was suitable for bedside use. Clinical VTE events are rare in medical patients, and medical VTE thromboprophylaxis needs to be more focused. The new guideline has performance characteristics th@satisfy this need.

8098 POSTER A study of at risk and deteriorating cancer patients: the impact of a nurse-led critical care outreach service

To identify the relationship between one example of a rapid response system (RRS), specifically, an after-hours Clinical Team Co-Ordinator (CTC), and the incidence of Medical Emergency Team (MET) activations and, adverse and major adverse events in medical patients.A retrospective chart audit of patients’ medical records was undertaken. The intervention group consisted of 150 randomly selected medical patients admitted during three months after the introduction of the CTC after-hours service. The control group consisted of 150 randomly selected medical patients admitted before the introduction of the after-hours CTC service. Multiple logistic regression was used to determine which of the potential predictors, along with the after-hours CTC service, were associated with adverse and major adverse events.A total of 130 patients (n = 63, 42% control; n = 67, 45% intervention) exhibited physiological abnormalities that should have activated the MET yet it was only activated five times. In total there were 69 adverse events (n = 32, 21% control; n = 36, 25% intervention) and 25 major adverse events (n = 7, 5% control; n = 18, 12% intervention). There were more adverse and major adverse events identified after the introduction of the CTC after-hours service. Changes in heart rate and reduction in Glasgow Coma Scores (GCS) were significant predictors of an adverse event. A low urine output and a drop of two or more in the GCS were significant predictors of a major adverse event.The introduction of an after-hours CTC service in a specific clinical site was associated with an increase in the identification of adverse and major adverse events in medical patients. Further exploration of nurse-led rapid response systems should be undertaken in different clinical settings.

Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients?

Language barriers may lead to medical errors by impeding patient-provider communication. The objective of this study was to determine whether hospitalized pediatric patients whose families have language barriers are more likely to incur serious medical errors than patients whose families do not have language barriers. A case-control study was conducted in a large, academic, regional children's hospital in the Pacific Northwest. Case patients (n = 97) included all hospitalizations of patients who were younger than 21 years and had a reported serious medical event from January 1, 1998, to December 31, 2003. Control patients (n = 475) were chosen from hospitalizations without a reported serious medical event and were matched with case patients on age, admitting service, admission to intensive care, and date of admission. The main exposure was a language barrier defined by self- or provider-reported need for an interpreter. Serious medical events were defined as events that led to unintended or potentially adverse outcomes identified by the hospital's quality improvement staff. Fourteen (14.4%) of the case patients and 53 (11.2%) of the control patients were assigned an interpreter during their hospitalization. Overall, we found no increased risk for serious medical events in patients and families who requested an interpreter compared with patients and families who did not request an interpreter (odds ratio: 1.36; 95% confidence interval: 0.73-2.55). Spanish-speaking patients who requested an interpreter comprised 11 (11.3%) of the case patients and 26 (5.5%) of the control patients. This subgroup had a twofold increased risk for serious medical events compared with patients who did not request an interpreter (odds ratio: 2.26; 95% confidence interval: 1.06-4.81). Spanish-speaking patients whose families have a language barrier seem to have a significantly increased risk for serious medical events during pediatric hospitalization compared with patients whose families do not have a language barrier.

Comparison of the efficacy and tolerability of mepifylline oral solution versus inhaled ipratropium bromide in patients with stable chronic obstructive pulmonary disease: A randomized, active-controlled, open-label study

Background: Inhaled ipratropium bromide, through a metered-dose inhaler (MDI), is a first-line treatment for the prevention of exacerbations of chronic obstructive pulmonary disease (COPD). However, MDIs are often used incorrectly by patients, and the efficacy of inhaled medications may be affected as a result. Objective: The purpose of this study was to compare the efficacy and tolerability of inhaled ipratropium bromide versus oral mepifylline in the prevention of medical events among patients with COPD. Methods: This was an open-label, randomized, parallel-group, active-controlled study. Patients with stable COPD were randomly assigned to receive 75 mg mepifylline by the oral route every 8 hours or 0.04 mg ipratropium bromide inhaled every 6 hours, for 6 months. A medical event was defined as any unanticipated, COPD-related event requiring extra medical care. Secondary end points were pulmonary function, intensity of dyspnea on the Borg scale, distance on the 6-minute walking test (and intensity and subjective feelings of dyspnea before and/or after the test), blood gas and inspiratory pressures, and use of any type of medication to control COPD symptoms. Results: A total of 134 patients were enrolled. After 6 months of treatment, oral mepifylline and inhaled ipratropium bromide were equally effective in preventing medical events. Forced expiratory volume in 1 second (FEV 1) and forced vital capacity (FVC) decreased slightly but significantly versus baseline ( P = 0.018). In both groups, a decrease in dyspnea ( P = 0.054) and an increase in the distance covered in the walking test were observed. The subjective feeling of dyspnea after the 6-minute walking test decreased significantly among the patients treated with mepifylline ( P = 0.01 vs baseline), but not among those treated with ipratropium bromide ( P = 0.172 vs baseline). The need for rescue medication decreased throughout the study, with no differences between treatment groups. A significantly greater number of gastrointestinal adverse events were seen in the mepifylline group ( P = 0.003). Conclusion: Mepifylline is as effective as ipratropium bromide in controlling symptoms and preventing medical events in patients with COPD, and can be considered a good therapeutic alternative to inhaled ipratropium bromide.

Predictors of medical events in patients enrolled in the Cardiac Insufficiency Bisoprolol Study (CIBIS): A study of the interactions between [beta ]-blocker therapy and occurrence of critical events using analysis of competitive risks

The risk of occurrence of medical events in a clinical trial is competitive in nature; that is, in a given patient the risk of having a critical event depends on the amount of time elapsed since random assignment and on the previous events that may have occurred in the patient. The purpose of this study was to examine the relations between baseline variables, the interactions between treatment, bisoprolol, or placebo, and the occurrence of critical events during the CIBIS trial, a mortality and morbidity trial of beta-blockade in patients with heart failure. A Cox model for censored data was used to analyze the relations between baseline variables, total deaths, permanent treatment withdrawals, nonlethal cardiovascular events, and their interactions with bisoprolol or placebo. We examined the influence of treatment on the occurrence of deaths, permanent treatment withdrawals, and nonlethal cardiovascular events by using the technique of event history analysis, which takes into account competitive risks between events. Compared with placebo, bisoprolol reduced mortality rates in patients with a left ventricular ejection fraction < or =20% (relative risk [RR] 0.49; 95% confidence interval [CI] 0.27 to 0.88; P =.02). In patients whose baseline heart rate was in the upper tertile of distribution, permanent treatment withdrawals were less frequent in patients randomly assigned to bisoprolol than in patients randomly assigned to placebo (RR 0.50; 95% CI 0.28 to 0.88; P =.02). Bisoprolol reduced the incidence of nonlethal cardiac events in patients in whom heart failure was present for at least 4 years (RR 0.44; 95% CI 0.27 to 0.71; P <.01). Event history analysis revealed that among patients who died under treatment after having at least 1 nonlethal cardiovascular event, 20 patients were treated with placebo but only 7 patients were treated with bisoprolol (RR 0.41; 95% CI 0.17 to 0.98; P <.05). Some patients with heart failure derive more benefit from beta-blocker therapy than others. In the CIBIS trial, they are those patients with the lower left ventricular ejection fractions and those who have nonlethal cardiovascular events but in whom beta-blocker therapy is not permanently discontinued.

Predictors of medical events in patients enrolled in the cardiac insufficiency bisoprolol study (CIBIS): A study of the interactions between β-blocker therapy and occurrence of critical events using analysis of competitive risks

Background The risk of occurrence of medical events in a clinical trial is competitive in nature; that is, in a given patient the risk of having a critical event depends on the amount of time elapsed since random assignment and on the previous events that may have occurred in the patient. The purpose of this study was to examine the relations between baseline variables, the interactions between treatment, bisoprolol, or placebo, and the occurrence of critical events during the CIBIS trial, a mortality and morbidity trial of β-blockade in patients with heart failure. Methods and Results A Cox model for censored data was used to analyze the relations between baseline variables, total deaths, permanent treatment withdrawals, nonlethal cardiovascular events, and their interactions with bisoprolol or placebo. We examined the influence of treatment on the occurrence of deaths, permanent treatment withdrawals, and nonlethal cardiovascular events by using the technique of event history analysis, which takes into account competitive risks between events. Compared with placebo, bisoprolol reduced mortality rates in patients with a left ventricular ejection fraction ≤20% (relative risk [RR] 0.49; 95% confidence interval [Cl] 0.27 to 0.88; P = .02). In patients whose baseline heart rate was in the upper fertile of distribution, permanent treatment withdrawals were less frequent in patients randomly assigned to bisoprolol than in patients randomly assigned to placebo (RR 0.50; 95% Cl 0.28 to 0.88; P = .02). Bisoprolol reduced the incidence of nonlethal cardiac events in patients in whom heart failure was present for at least 4 years (RR 0.44; 95% Cl 0.27 to 0.71; P < .01). Event history analysis revealed that among patients who died under treatment after having at least 1 nonlethal cardiovascular event, 20 patients were treated with placebo but only 7 patients were treated with bisoprolol (RR 0.41; 95% Cl 0.17 to 0.98; P < .05). Conclusions Some patients with heart failure derive more benefit from β-blocker therapy than others. In the CIBIS trial, they are those patients with the lower left ventricular ejection fractions and those who have nonlethal cardiovascular events but in whom β-blocker therapy is not permanently discontinued.

Potential identifiability and preventability of adverse events using information systems.

To evaluate the potential ability of computerized information systems (ISs) to identify and prevent adverse events in medical patients. Clinical descriptions of all 133 adverse events identified through chart review for a cohort of 3,138 medical patients were evaluated by two reviewers. For each adverse event, three hierarchical levels of IS sophistication were considered: Level 1--demographics, results for all diagnostic tests, and current medications would be available on-line; Level 2--all orders would be entered on-line by physicians; and Level 3--additional clinical data, such as automated problem lists, would be available on-line. Potential for event identification and potential for event prevention were scored by each reviewer according to two distinct sets of event monitors. Of all the adverse events, 53% were judged identifiable using Level 1 information, 58% were judged identifiable using Level 2 information, and 89% were judged identifiable using Level 3 information. The highest-yield event monitors for identifying adverse events were "panic" laboratory results, unexpected transfer to an intensive care unit, and hospital-incurred trauma. With information from Levels 1, 2, and 3, 5%, 13%, and 23% of the adverse events, respectively, were judged preventable. For preventing these adverse events, guided-dose algorithms, drug-laboratory checks, and drug-patient characteristic checks held the most potential.