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Aim of the study: Early paracentesis before antibiotic administration reduces morbidity and mortality in patients with decompensated cirrhosis. We studied the association of variables with antibiotic administration before or after performing paracentesis. Material and methods: This was a retrospective study of 137 patients with ascites secondary to cirrhosis admitted to a community hospital in New York City. Predictor variables were demographic, disease-related, admission timing, and serum measurement. Results: We found a significantly increased relative risk for performing paracentesis after antibiotic administration for those admitted at night (relative risk ratio [RRR] = 3.01, 95% CI: 1.02-8.85, p = 0.046). Demographic, disease-related, and serum measurement variables were not significantly associated with performing paracentesis or order of antibiotic administration. Also, increased body mass index was significantly associated with decreased relative risk for paracentesis not done (RRR = 0.84, 95% CI: 0.74-0.96, p = 0.01). Conclusions: In conclusion, there was increased relative risk for performing paracentesis after antibiotic administration for patients admitted at night. We recommend ongoing resident and hospitalist training to maintain competency in bedside procedures such as paracentesis for patients with cirrhosis. Also, increased staffing or the presence of a resident/hospitalist led interventional team during night shifts may also help optimize the rates of timely paracentesis.
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INTRODUCTION: Long term management of patients with stable coronary artery disease of >1âyear after myocardial infarction (MI) or percutaneous coronary intervention and atrial fibrillation is unclear. Current guidelines recommend using oral anti-coagulation (OAC) alone although the recommendation is weak and there is low quality evidence. Two new randomized control trials (RCTs) were published recently. We conducted an updated meta-analysis to evaluate the effect of these studies on patient outcomes. OBJECTIVE: To conduct a systematic review and meta-analysis of published RCTs and observational studies to compare OAC alone versus OAC plus single anti-platelet therapy. METHODS: Electronic searches were conducted using appropriate terms from 3 databases. Relevant studies included. Data extracted and analysis were performed using STATA. MEASUREMENTS: Summary statistics were pooled and measured for primary and secondary outcomes of both treatment arms. MAIN RESULTS: Eight studies involving 10,120 patients were included for the analysis. Five thousand two hundred thirty-seven patients were on combination therapy while 4883 were on OAC alone. There was no statistically significant difference in the primary outcome of major adverse cardiac events (hazard ratio [HR] 1.067; 95% confidence interval [CI] 0.912-1.249; P value .417). There was no statistically significant difference even in the measured secondary outcomes namely all cause mortality (HR 1.048; 95% CI 0.830-1.323; P value .695), cardiovascular mortality (HR 0.863; 95% CI 0.593-1.254; P value .439). However, we found statistically significant difference between the 2 groups in the incidence of MI with higher incidence in mono therapy group (HR 1.229; 95% CI 1.011-1.495; P value .039) and higher incidence of major bleeding in the combination therapy group in the subgroup analysis (HR 0.649; 95% CI 0.464-0.907; P value .011). CONCLUSION: We found no reduction of major adverse cardiac event between combination therapy and mono therapy. Although mono therapy showed increased risk of major bleeding overall, subgroup analysis of the RCTs showed increased risk of major bleeding in the combination therapy group. MI was higher in the mono therapy group compared to the combination therapy group, however this outcome was not reproducible in the subgroup analysis of the RCTs.
