Transitioning from hospital to home with non-invasive ventilation: who benefits? Results of a cohort study.

BACKGROUND: Non-invasive ventilation (NIV) is effective in a variety of acute respiratory illnesses in hospitalised patients. Home NIV is effective for stable patients with hypercapnia due to neuromuscular or chronic pulmonary disease. However, there are little data to guide which patients may benefit from NIV immediately following hospitalisation with hypercapnia. OBJECTIVE: To evaluate outcomes of patients with daytime hypercapnia at the end of an acute hospital admission. DESIGN: Retrospective cohort study. PARTICIPANTS: Entry into the cohort was by querying the hospital electronic medical system for consultations regarding NIV after discharge. Cases received NIV and controls did not. We extracted data on demographics, ICD-9 diagnoses and medications coded at admission, blood gas measurements and dates of discharge, first readmission and death. INTERVENTION: None. MAIN MEASUREMENT: Time from hospital discharge to mortality or readmission. KEY RESULTS: We identified 585 cases and 53 controls who survived to discharge at the index admission. Cases and controls were broadly similar in age and Charlson Comorbidity Index. In the whole cohort, cases treated with home NIV were at increased risk of death compared with controls (HR 1.88 95% CI 1.17 to 3.03). In multivariate Cox regression for all-cause mortality, poor prognostic factors were increasing age (HR 1.03 per year, 95% CI 1.02 to 1.04), cardiac failure (HR 1.31, 95% CI 1.01 to 1.67) and failure to attend NIV follow-up (HR 2.33, 95% CI 1.33 to 4.10). In contrast, chronic respiratory disease was associated with improved prognosis (HR 0.77, 95% CI 0.61 to 0.97) as was sleep apnoea (HR 0.44, 95% CI 0.23 to 0.83). Cases did not have different time-to-readmission compared with controls (HR 1.42 95% CI 0.99 to 2.02). CONCLUSION: Transitioning to home NIV after a hypercapnic hospitalisation may be useful in younger, co-operative patients with chronic respiratory disease. For older patients or those with cardiac failure, home NIV may not be beneficial and may potentially be harmful.

Thoracentesis under clopidogrel is not associated with excessive bleeding events: a cohort study.

BACKGROUND: Thoracentesis is a low-risk procedure for bleeding (approx. 2%). Data regarding safety of thoracentesis under treatment with clopidogrel is scarce, and current guidelines are not evidence based. We performed a retrospective study to evaluate the rate of bleeding complications of thoracentesis under clopidogrel in hospitalized patients. METHODS: Retrospective chart review of hospitalized patients undergoing thoracentesis with or without clopidogrel treatment. Demographic and clinical data, diagnostic ICD9 codes, and use of ultrasound were extracted. Bleeding endpoints were defined as hemothorax, drop of > 2 g/dL hemoglobin, or need for packed red cell transfusion. RESULTS: The study group comprised of 88 cases and 169 controls. Four bleeding complications were noted in the cases group, versus 5 in the control group (RR 1.53, 95% CI 0.4-5.5). CONCLUSION: Thoracentesis may be performed safely in patients receiving clopidogrel. Bleeding event rates are consistent with previous reports of thoracentesis in general.

Potential impact of removing metronidazole from treatment armamentarium of mild acute Clostridioides difficile infection.

Aim: Recent guidelines recommended removing metronidazole as a therapeutic option for Clostridioides difficile infections (CDI). However, superiority of vancomycin over metronidazole in mild CDI is not established and use of vancomycin might lead to emergence of vancomycin-resistant enterococci (VRE). Patients & methods: A retrospective cohort study and efficacy analyses were conducted at Shamir Medical Center, Israel (2010-2015), among adults with acute CDI. Results: A total of 409 patients were enrolled. In multivariable analyses, metronidazole was noninferior to vancomycin for mild CDI, but vancomycin was an independent predictor for post-CDI VRE acquisition. Conclusion: A significant independent association was evident between treatment with vancomycin and, later, acquisition of VRE. In first episodes of mild acute CDI, metronidazole should be considered a valid therapeutic option.