VTE prophylaxis in pregnant people with chronic physical disability: Data from a physicians survey and the need for guidance.

Background: International guidelines recommend risk assessment during the antepartum and postpartum period to inform VTE prophylaxis. We aimed to evaluate physicians' approach to VTE prophylaxis of women with chronic physical disability (CPD) during pregnancy. Methods: A cross-sectional study consisting of a self-administered electronic questionnaire was sent to specialists across Canada. Results: Seventy-three participants responded to the survey, and 55 (75.3%) completed the survey including 33 (60%) Maternal Fetal Medicine (MFM) specialists and 22 (40%) Internal Medicine (IM) specialists including physicians with an interest in Obstetric Medicine. Our study shows considerable variation in VTE thromboprophylaxis during pregnancy with CPD. Most respondents favoured antepartum (67.3%) and postpartum (65.5%) VTE prophylaxis for pregnancies within a year of spinal cord injury. Conclusions: In order to better manage this complex population, CPD should be considered as a risk factor for development of VTE.

Health Experiences of Nurses during the COVID-19 Pandemic: A Mixed Methods Study.

This study characterizes the impact of the COVID-19 pandemic on the mental and physical health of nurses. Qualitative data (collected using semi-structured interviews) were integrated with quantitative data (collected concurrently using the SF-12 Health Survey). Nurses (N = 30) compared their health prior to and during the first pandemic wave (March-May 2020). Interviews were analyzed thematically; descriptive statistics and t-tests compared pre-pandemic to current SF-12 scores. Qualitative findings demonstrated an impact on nurses' mental health expressed as isolation, loss, intense emotions, and feelings of being expendable. Impact on nurses' physical health included exhaustion, personal protective equipment skin breakdown, limited breaks from work, and virus exposure. Quantitative results show nurses' experienced declines in overall mental health (p < .001), and multiple physical health domains: role limitations due to physical problems (p < .0001), bodily pain (p < .0001), and general health (p < .0001). Promotion of nurses' well-being and safety, as well as education in emergency preparedness, must be given precedence to protect nurses' health.

Postpartum Hemorrhage in Women with von Willebrand Disease: Consider Other Etiologies.

OBJECTIVE: Higher rates of postpartum hemorrhage (PPH) have been reported for women with von Willebrand disease (VWD). Comprehensive multidisciplinary care reduces these rates; thus PPH may not be secondary to VWD. METHODS: We conducted a retrospective review for the period of 2009-2018, including all VWD pregnancies at 2 tertiary care academic hospitals to determine rates, etiology, and timing of PPH. RESULTS: A total of 63 women with 80 pregnancies were included. Three women had twin pregnancies. Sixty-six pregnancies (82.5%) involved type 1 VWD; 4 (5.0%), type 2 (unclear subtype); 3 (3.8%) type 2A; 3 (3.8%) type 2B; and 2 (2.5%), type 2M. Median age of patients was 32.9 years (range 19-43 y). Most patients were blood type O (65%), and 33 of 80 pregnancies (41.3%) were nulliparous. The mean bleeding assessment score was 8 (range 0-16). Thirty-seven pregnancies (46.3%) received prophylactic hemostatic treatment prior to delivery. Seventy-four percent of pregnancies were delivered vaginally, and 88% received epidural anaesthesia. The majority of pregnancies (78.8%) had von Willebrand factor (VWF) levels assessed during the third trimester, with most (71.3%) achieving VWF levels above 1.00 IU/mL. Four pregnancies (5.2%) were complicated by primary PPH; uterine atony in 2 and placenta previa in 1. Delayed postpartum bleeding occurred in 5 pregnancies (6.3%). CONCLUSION: Multidisciplinary care of pregnancies with VWD improves outcomes. Rates of primary and delayed PPH in this study are lower than previously described and are similar to those of women without VWD. In women with VWD, uterine etiologies for primary PPH need to be considered, in a manner similar to the assessment of women without VWD, to ensure hemostasis is achieved.

Ecological network complexity scales with area.

Larger geographical areas contain more species-an observation raised to a law in ecology. Less explored is whether biodiversity changes are accompanied by a modification of interaction networks. We use data from 32 spatial interaction networks from different ecosystems to analyse how network structure changes with area. We find that basic community structure descriptors (number of species, links and links per species) increase with area following a power law. Yet, the distribution of links per species varies little with area, indicating that the fundamental organization of interactions within networks is conserved. Our null model analyses suggest that the spatial scaling of network structure is determined by factors beyond species richness and the number of links. We demonstrate that biodiversity-area relationships can be extended from species counts to higher levels of network complexity. Therefore, the consequences of anthropogenic habitat destruction may extend from species loss to wider simplification of natural communities.

Incorporating abiotic controls on animal movements in metacommunities.

Local dynamics are influenced by regional processes. Meta-ecology, or the study of spatial flows of energy, materials, and species between local systems, is becoming increasingly concerned with accurate depictions of species movements and the impacts of this movement on landscape-level ecosystem function. Indeed, incorporating diverse types of movement is a major frontier in metacommunity theory. Here, we synthesize literature to demonstrate that the movement of organisms between patches is governed by the interplay between both a species' ability to move and the combined effects of landscape structure and physical flows (termed abiotic controls), which together we refer to as abiotic-dependent species connectivity. For example, two lakes that share geographic proximity may be inaccessible for mobile fish species because they lack a river connecting them (landscape structure), but wind currents may disperse insects between them (physical flows). Empirical evidence suggests that abiotic controls, such as ocean currents, lead to abiotic-dependent species connectivity and that, in nature, this type of connectivity is the rule rather than the exception. Based on this empirical evidence, we introduce a novel mathematical framework to demonstrate how species movement capabilities and abiotic conditions, can interact to influence metacommunity stability. We apply this framework to predict how incorporating abiotic-dependent species connectivity applies to classic empirical examples of aquatic, aquatic-terrestrial, and terrestrial experimental metacommunities. We demonstrate that incorporating abiotic-dependent species connectivity into metacommunity models can lead to a much broader range of dynamics than models previously predicted, including a wider range of metacommunity stability. Our framework fills critical gaps in our basic understanding of organismal movement across landscapes and provides testable predictions for how such common natural phenomena impact landscape-level ecosystem function. Finally, we present future perspectives for further development of meta-ecological theory from questions about fragmentation to ecosystems. Anthropogenic change is not only leading to habitat loss from the damming of rivers to denuding the landscape, but altering the physical flows that have historically connected communities. Thus, recognizing the importance of these processes in tandem with species' movement abilities is critical for predicting and preserving the structure and function of ecological communities.

The multiple meanings of omnivory influence empirical, modular theory and whole food web stability relationships.

The persistence of whole communities hinges on the presence of select interactions which act to stabilize communities making the identification of these keystone interactions critical. One potential candidate is omnivory, yet theoretical research on omnivory thus far has been dominated by a modular theory approach whereby an omnivore and consumer compete for a shared resource. Empirical research, however, has highlighted the presence of a broader suite of omnivory modules. Here, we integrate empirical data analysis and mathematical models to explore the influence of both omnivory module (including classic, multi-resource, higher level, mutual predation and cannibalism) and omnivore-resource interaction type on food web stability. We use six classic empirical food webs to examine the prevalence of the different types of omnivory, a multi-species consumer-resource model to determine the stability of these different kinds of omnivory within a module context, and finally extend these models to a 50 species, whole food web model to examine the influence of omnivory on whole food web persistence. Our results challenge the concept that omnivory is broadly stabilizing. In particular, we demonstrate that the impact of omnivory depends on the type of omnivory being examined with multi-resource omnivory having the largest correlation with whole food web persistence. Moreover, our results highlight that we need to exercise caution when scaling modular theory to whole food web theory. Cannibalism, for example, was the most persistent and stable omnivory module in the modular theory analysis, but only demonstrated a weak correlation with whole food web persistence. Lastly, our results demonstrate that the frequency of omnivory modules are more important for whole food web persistence than the frequency of omnivore-resource interactions. Together, these results demonstrate that the role of omnivory often depends both on the type of omnivory being examined and the food web within which it is nested. In whole food web models, omnivory acts less as a keystone interaction, rather, specific types of omnivory, particularly multi-resource omnivory, act as keystone modules. Future work integrating module and whole food web theory is critical for resolving the role of key interactions in food webs.

Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests.

PURPOSE: To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD: In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS: For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS: In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.

Use of a Food Web Bioaccumulation Model to Uncover Spatially Integrated Polychlorinated Biphenyl Exposures in Detroit River Sport Fish.

We applied and tested a bioenergetic-based, steady-state food web bioaccumulation model to predict polychlorinated biphenyl (PCB) exposures in sport fish of the Detroit River (USA-Canada), which is a Great Lakes area of concern. The PCB concentrations in the sediment and water of the river were found to exhibit high spatial variation. The previously contained areas of high contamination may have spread to adjacent food webs as a result of fish movements. This process may cause biased predictions in single-compartment bioaccumulation models. We performed multiple simulations and contrasted model predictions against a database of 1152 fish sample records comprising 19 sport fish species. The simulations evaluated 4 spatial scales (river-wide, 2-nation, 4-zone, and 6-zone models) to reveal how the spatial heterogeneity of contamination and species-specific movements contribute to variation in fish PCB exposures. The model testing demonstrated that the 2-nation model provided the most accurate global prediction of fish contamination. However, these improvements were not equally observed across all species. The model was subsequently calibrated for poorly performing species, by allowing cross-zone exposures, demonstrating the importance of accounting for specific ecological factors, such as fish movement, to improve PCB bioaccumulation prediction, especially in highly heterogeneous water systems. Environ Toxicol Chem 2019;38:2771-2784. © 2019 SETAC.

Management of anticoagulation in patients with metastatic castration-resistant prostate cancer receiving abiraterone + prednisone.

PURPOSE: Abiraterone has been proven to be an effective agent used in the management of metastatic castration-resistant prostate cancer, significantly improving overall and progression-free survival. Due to the pharmacodynamic and pharmacokinetic properties of abiraterone, concurrent use with anticoagulation may pose a challenge for clinicians. Thrombosis within the cancer setting continues to increase patient mortality; therefore, appropriate anticoagulation through the use of a management algorithm can reduce adverse events and increase quality of life. METHODS: A review of the literature was preformed by a medical oncologist, haematologist and pharmacists to identify relevant randomized controlled trials, meta-analyses and retrospective studies. Major society guidelines were reviewed to further aid in developing the anticoagulation protocol for non-valvular atrial fibrillation and venous thromboembolism within this patient population. After reviewing the literature, a clinical framework was designed to aid clinicians in the management of those patients receiving abiraterone concurrently with an anticoagulant. RESULTS: In this review, we describe the potential interactions between abiraterone and various anticoagulants and provide management strategies based on the most recent literature for atrial fibrillation, venous thromboembolism and mechanical heart valves to avoid potential drug-drug interactions. CONCLUSION: Abiraterone therapy has become a mainstay of the management of advanced prostate cancer and is often used over prolonged years. In this review, we have summarized a framework of how to use abiraterone in men with prostate cancer on anticoagulants. Evidence available to date suggests that patients with an indication for anticoagulation such as atrial fibrillation, venous thromboembolism and mechanical heart valves can be treated safely with abiraterone in the appropriate setting, with appropriate monitoring.

A Multitracer Approach to Quantifying Resource Utilization Strategies in Lake Trout Populations in Lake Huron.

Lake ecosystems are threatened by an array of stressors. An understanding of how food webs and bioaccumulation dynamics respond to these challenges requires the quantification of energy flow. We present a combined, multitracer approach using both polychlorinated biphenyls (PCBs) and stable isotopes to trace energy flow, and to quantify how lake trout feeding strategies have adapted to changes in food web structure in 3 basins of Lake Huron (ON, Canada). This combined tracer approach allows the quantification of dietary proportions (using stable isotopes), which are then integrated using a novel PCB tracer approach that employs knowledge of PCB bioaccumulation pathways, to estimate consumption and quantify energy flow between age cohorts of individual fish across Lake Huron. We observed basin-specific differences in ultimate energy sources for lake trout, with Georgian Bay lake trout deriving almost 70% of their energy from benthic resources compared with 16 and 33% for Main Basin and North Channel lake trout, respectively. These differences in resource utilization are further magnified when they are contrasted with age. The dependency on pelagic energy sources in the Main Basin and North Channel suggests that these populations will be the most negatively affected by the ongoing trophic collapse in Lake Huron. Our study demonstrates the utility of a multitracer approach to quantify the consequences of food web adaptations to changes in aquatic ecosystems. Environ Toxicol Chem 2019;38:1245-1255. © 2019 SETAC.

Characterizing polychlorinated biphenyl exposure pathways from sediment and water in aquatic life using a food web bioaccumulation model.

Contaminant remediation decisions often focus on sediment-organism relationships, omitting the partitioning between sediment and water that exists across a given site. The present study highlights the importance of incorporating nonsedimentary routes of exposure into a nonequilibrium, steady-state food web bioaccumulation model for predicting polychlorinated biphenyl (PCB) concentrations in benthic invertebrates. Specifically, we examined the proportion of overlying water relative to the sediment porewater respired by benthic invertebrates, which has been used in previous studies to examine contaminant bioaccumulation. We evaluated the model accuracy using paired benthos-sediment samples and an extensive fish contamination database to ensure realistic predictions at the base of the Detroit River (Ontario, Canada, and Michigan, USA) food web. The results demonstrate that, compared with empirical regression analyses, the food web bioaccumulation model provided satisfactory estimates of PCB bioaccumulation for benthos simulations and better estimates for fish simulations. Our results showed that PCB bioaccumulation measurements are significantly affected by variations in pollutant uptake and elimination routes via the overlying water, which in turn are affected by the degree of disequilibrium of PCBs between sediments and water. Interestingly, we obtained contrasting results regarding the effectiveness of remediation strategies for reducing the contaminant burden of the aquatic biota based on different proportions of overlying water relative to porewater. These differences could consequently impact decisions about the approaches for source control and strategic sediment remediation. This study suggests that bioaccumulation assessments could be improved through better identification of chemical uptake-elimination routes in benthos and by accounting for chemical bioavailability in sediment and water components in areas with disequilibrium.Integr Environ Assess Manag 2019;00:000-000. © 2019 SETAC.

Is anemia an independent risk factor for postpartum depression in women who have a cesarean section? - A prospective observational study.

BACKGROUND: The symptoms of anemia and depression are very similar suggesting that there may be an association between the two entities. The aim of this study is to assess whether postpartum anemia (PPA) is an independent risk factor for de novo postpartum depression (PPD)in women undergoing elective cesarean section. METHODS: Women after an uncomplicated term cesarean section were recruited and their hemoglobin and iron status were measured on day 3-5 post section and again at 6 weeks. Postpartum depression was screened using the Edinburgh Postnatal Depression Scale (EPDS) and functional capacity was assessed with the RAND 12-item Health survey. RESULTS: One hundred and three women completed the study. The incidence of probable postpartum depression (PPD) as defined by EPDS score ≥ 10 was 17% at 6 weeks. There was no difference in hemoglobin or iron status in women who had PPD compared to those without (OR-0.69; 95% CI-0.15-2.49). Similarly, there was no significant association between low hemoglobin and maternal functional status (OR -1.03; 95% CI-0.34 - 2.94). CONCLUSIONS: Neither anemia or low iron stores were found to be an independent risk factors for postpartum depression or decreased postpartum functional capacity in women who undergo an elective cesarean section.

The Approach to Peripartum Management of Anticoagulation: A Multidisciplinary Survey.

OBJECTIVE: This study sought to determine whether there is practice variation in the treatment and prevention of acute venous thromboembolism (VTE) in pregnant patients, potentially to prioritize future studies. BACKGROUND: The risk of VTE during pregnancy is five-fold that of the non-pregnant state. Guidance is often lacking for the treatment and prophylaxis of VTE because there are few RCTs. METHODS: The study used a cross-sectional study design using a self-administered electronic questionnaire consisting of 11 case scenarios that were sent to hematologists, maternal-fetal medicine specialists, obstetricians and gynaecologists, and internal medicine specialists across Canada. RESULTS: A total of 254 participants responded to the survey and 193 (76%) completed the survey, 158 of whom indicated that they were involved in the decision to anticoagulate these patients. Anticoagulation of patients with superficial venous thrombosis during pregnancy, monitoring of low-molecular-weight heparin antepartum, and discontinuation of this agent at the time of delivery were the scenarios associated with the largest variability of responses. For the management of acute VTE antepartum, most participants favoured a once-daily regimen, although internists more so than obstetrics and gynaecology physicians (94.7% vs. 73.7%). Cesarean section was not perceived to be a procedure with a marked increased risk of thrombosis to warrant thromboprophylaxis because most physicians elected not to offer thromboprophylaxis for this scenario. However, obesity and severe preeclampsia with Cesarean section led to the predominant use of thromboprophylaxis, at 80.0% and 68.4%, respectively. CONCLUSION: Prospective studies addressing peripartum management where significant discrepancies exist are warranted.

The effect of chronotherapy on delirium in critical care - a systematic review.

BACKGROUND: Delirium is highly prevalent within critical care and is linked to adverse clinical outcomes, increased mortality and impaired quality of life. Development of delirium is thought to be caused by multiple risk factors, including disruption of the circadian rhythm. Chronotherapeutic interventions, such as light therapy, music and use of eye shades, have been suggested as an option to improve circadian rhythm within intensive care units. AIM: This review aims to answer the question: Can chronotherapy reduce the prevalence of delirium in adult patients in critical care? DESIGN: This study is a systematic review of quantitative studies. RESEARCH METHOD: Six major electronic databases were searched, and a hand search was undertaken using selected key search terms. Research quality was assessed using the critical appraisal skills programme tools. The studies were critically appraised by both authors independently, and data were extracted. Four themes addressing the research question were identified and critically evaluated. FINDINGS: Six primary research articles that investigated different methods of chronotherapy were identified, and the results suggest that multi-component non-pharmacological interventions are the most effective for reducing the prevalence of delirium in critical care. The melatonergic agonist Ramelteon demonstrated statistically significant reductions in delirium; however, the reliability of the results in answering the review question was limited by the research design. The use of bright light therapy (BLT) and dynamic light application had mixed results, with issues with the research design and outcomes measured limiting the validity of the findings. CONCLUSION: Multi-component non-pharmacological interventions, such as noise and light control, can reduce delirium in critical care, whereas other interventions, such as BLT, have mixed outcomes. Melatonin, as a drug, may be a useful alternative to sedative-hypnotics. RELEVANCE TO CLINICAL PRACTICE: Chronotherapy can reduce the incidence of delirium within critical care, although further research is warranted. Staff education is essential in the implementation of chronotherapy.

Thromboembolism following cesarean section: a retrospective study.

OBJECTIVES: As thromboembolism (TE) continues to be one of the principal causes of death in obstetrical patients and as the postpartum period is associated with the highest risk for TE, we sought to determine the risk factors associated with TE following cesarean section (CS). METHODS: A retrospective analysis of patients who had CS at a large tertiary referral center was conducted. Patients were identified through hospital medical records and were contacted approximately 1 year following their CS. Medical records and a questionnaire were used to identify features that were potentially associated with TE. Univariate analysis was used to determine the risk associated with these characteristics. RESULTS: A total of 2206 patients had a CS, of which 1377 (62%) participated. Of the respondents, 137 patients received heparin (94% received a prophylactic dose, 6% received a therapeutic dose) and the remainder, 1233 patients, did not receive heparin. Seven patients (0.5%) developed a TE and 86% developed a TE within 7 days of CS. The odds ratio (OR) for TE for women with hypertension prior to pregnancy compared to patients who did not receive anticoagulation was 21.28 [95% confidence interval (CI) 4.64-90.13] and for patients who had varicose veins with superficial thrombophlebitis when compared to patients who had received heparin postpartum was 21.01 (95% CI 1.55-288.24). DISCUSSION: Hypertension and the presence of varicose veins were associated with TE following CS. Larger cohort analyses are required to confirm these associations so that risk scores incorporating these characteristics may accurately predict the occurrence of TE.

Anemia in Pregnancy: A Pragmatic Approach.

IMPORTANCE: Anemia is common in pregnancy, ranging from 5.4% in developed countries to more than 80% in developing countries. Anemia in pregnancy has been associated with prematurity, low birth weight, and adverse pregnancy outcomes. OBJECTIVE: This review uses clinical vignettes to illustrate the clinical presentations, approach to diagnosis, maternal and fetal implications, and treatment for the common etiologies of anemia in pregnancy. EVIDENCE ACQUISITION: Literature review. RESULTS: Normal physiological changes in pregnancy result in alterations of hematological parameters particularly in a reduction of hemoglobin (Hb) concentration. Consequently, the Hb used to define anemia in pregnancy is lower than in nonpregnant patients. As there is an increased requirement of iron in pregnancy, it is not unexpected that iron deficiency remains the most common cause of anemia and warrants a preemptive approach to prevent a further reduction in Hb. The syndromes associated with microangiopathic hemolytic anemia may pose a diagnostic challenge, as there are several potential etiologies that may be difficult to differentiate, and microangiopathic hemolytic anemia can be associated with significant maternal and fetal morbidity andmortality. Anemia secondary to sickle cell disease and autoimmune hemolytic anemiamerit special attention because there are risks secondary to red blood cell transfusion and risks to withholding transfusion. CONCLUSIONS: Anemia in pregnancy is potentially associated with maternal and fetal adverse outcomes. Providing evidence-based care is essential to achieving the best pregnancy outcomes.

Association Between Use of Antithrombotic Medication and Hematuria-Related Complications.

Importance: Antithrombotic medications are among the most commonly prescribed medications. Objective: To characterize rates of hematuria-related complications among patients taking antithrombotic medications. Design, Setting, and Participants: Population-based, retrospective cohort study including all citizens in Ontario, Canada, aged 66 years and older between 2002 and 2014. The final follow-up date was December 31, 2014. Exposures: Receipt of an oral anticoagulant or antiplatelet medication. Main Outcomes and Measures: Hematuria-related complications, defined as emergency department visit, hospitalization, or a urologic procedure to investigate or manage gross hematuria. Results: Among 2 518 064 patients, 808 897 (mean [SD] age, 72.1 [6.8] years; 428 531 [53%] women) received at least 1 prescription for an antithrombotic agent over the study period. Over a median follow-up of 7.3 years, the rates of hematuria-related complications were 123.95 events per 1000 person-years among patients actively exposed to antithrombotic agents vs 80.17 events per 1000 person-years among patients not exposed to these drugs (difference, 43.8; 95% CI, 43.0-44.6; P < .001, and incidence rate ratio [IRR], 1.44; 95% CI, 1.42-1.46). The rates of complications among exposed vs unexposed patients (80.17 events/1000 person-years) were 105.78 for urologic procedures (difference, 33.5; 95% CI, 32.8-34.3; P < .001, and IRR, 1.37; 95% CI, 1.36-1.39), 11.12 for hospitalizations (difference, 5.7; 95% CI, 5.5-5.9; P < .001, and IRR, 2.03; 95% CI, 2.00-2.06), and 7.05 for emergency department visits (difference, 4.5; 95% CI, 4.3-4.7; P < .001, and IRR, 2.80; 95% CI, 2.74-2.86). Compared with patients who were unexposed to thrombotic agents, the rates of hematuria-related complications were 191.61 events per 1000 person-years (difference, 117.3; 95% CI, 112.8-121.8) for those exposed to both an anticoagulant and antiplatelet agent (IRR, 10.48; 95% CI, 8.16-13.45), 140.92 (difference, 57.7; 95% CI, 56.9-58.4) for those exposed to anticoagulants (IRR, 1.55; 95% CI, 1.52-1.59), and 110.72 (difference, 26.5; 95% CI, 25.9-27.0) for those exposed to antiplatelet agents (IRR, 1.31; 95% CI, 1.29-1.33). Patients exposed to antithrombotic agents, compared with patients not exposed to these drugs, were more likely to be diagnosed as having bladder cancer within 6 months (0.70% vs 0.38%; odds ratio, 1.85; 95% CI, 1.79-1.92). Conclusions and Relevance: Among older adults in Ontario, Canada, use of antithrombotic medications, compared with nonuse of these medications, was significantly associated with higher rates of hematuria-related complications (including emergency department visits, hospitalizations, and urologic procedures to manage gross hematuria).

Therapeutic hypothermia in patients following traumatic brain injury: a systematic review.

BACKGROUND: The efficacy of therapeutic hypothermia in adult patients with traumatic brain injury is not fully understood. The historical use of therapeutic hypothermia at extreme temperatures was associated with severe complications and led to it being discredited. Positive results from animal studies using milder temperatures led to renewed interest. However, recent studies have not convincingly demonstrated the beneficial effects of therapeutic hypothermia in practice. AIM: This review aims to answer the question: in adults with a severe traumatic brain injury (TBI), does the use of therapeutic hypothermia compared with normothermia affect neurological outcome? DESIGN: Systematic review. METHOD: Four major electronic databases were searched, and a hand search was undertaken using selected key search terms. Inclusion and exclusion criteria were applied. The studies were appraised using a systematic approach, and four themes addressing the research question were identified and critically evaluated. RESULTS: A total of eight peer-reviewed studies were found, and the results show there is some evidence that therapeutic hypothermia may be effective in improving neurological outcome in adult patients with traumatic brain injury. However, the majority of the trials report conflicting results. Therapeutic hypothermia is reported to be effective at lowering intracranial pressure; however, its efficacy in improving neurological outcome is not fully demonstrated. This review suggests that therapeutic hypothermia had increased benefits in patients with haematoma-type injuries as opposed to those with diffuse injury and contusions. It also suggests that cooling should recommence if rebound intracranial hypertension is observed. CONCLUSION: Although the data indicates a trend towards better neurological outcome and reduced mortality rates, higher quality multi-centred randomized controlled trials are required before therapeutic hypothermia is implemented as a standard adjuvant therapy for treating traumatic brain injury. RELEVANCE TO CLINICAL PRACTICE: Therapeutic hypothermia can have a positive impact on patient outcome, but more research is required.

Ecological Implications of Steady State and Nonsteady State Bioaccumulation Models.

Accurate predictions on the bioaccumulation of persistent organic pollutants (POPs) are critical for hazard and ecosystem health assessments. Aquatic systems are influenced by multiple stressors including climate change and species invasions and it is important to be able to predict variability in POP concentrations in changing environments. Current steady state bioaccumulation models simplify POP bioaccumulation dynamics, assuming that pollutant uptake and elimination processes become balanced over an organism's lifespan. These models do not consider the complexity of dynamic variables such as temperature and growth rates which are known to have the potential to regulate bioaccumulation in aquatic organisms. We contrast a steady state (SS) bioaccumulation model with a dynamic nonsteady state (NSS) model and a no elimination (NE) model. We demonstrate that both the NSS and the NE models are superior at predicting both average concentrations as well as variation in POPs among individuals. This comparison demonstrates that temporal drivers, such as environmental fluctuations in temperature, growth dynamics, and modified food-web structure strongly determine contaminant concentrations and variability in a changing environment. These results support the recommendation of the future development of more dynamic, nonsteady state bioaccumulation models to predict hazard and risk assessments in the Anthropocene.