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1.
PLoS One ; 14(12): e0226361, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31830138

RESUMO

BACKGROUND: Medical-related professions are at high suicide risk. However, data are contradictory and comparisons were not made between gender, occupation and specialties, epochs of times. Thus, we conducted a systematic review and meta-analysis on suicide risk among health-care workers. METHOD: The PubMed, Cochrane Library, Science Direct and Embase databases were searched without language restriction on April 2019, with the following keywords: suicide* AND (« health care worker* ¼ OR physician* OR nurse*). When possible, we stratified results by gender, countries, time, and specialties. Estimates were pooled using random-effect meta-analysis. Differences by study-level characteristics were estimated using stratified meta-analysis and meta-regression. Suicides, suicidal attempts, and suicidal ideation were retrieved from national or local specific registers or case records. In addition, suicide attempts and suicidal ideation were also retrieved from questionnaires (paper or internet). RESULTS: The overall SMR for suicide in physicians was 1.44 (95CI 1.16, 1.72) with an important heterogeneity (I2 = 93.9%, p<0.001). Female were at higher risk (SMR = 1.9; 95CI 1.49, 2.58; and ES = 0.67; 95CI 0.19, 1.14; p<0.001 compared to male). US physicians were at higher risk (ES = 1.34; 95CI 1.28, 1.55; p <0.001 vs Rest of the world). Suicide decreased over time, especially in Europe (ES = -0.18; 95CI -0.37, -0.01; p = 0.044). Some specialties might be at higher risk such as anesthesiologists, psychiatrists, general practitioners and general surgeons. There were 1.0% (95CI 1.0, 2.0; p<0.001) of suicide attempts and 17% (95CI 12, 21; p<0.001) of suicidal ideation in physicians. Insufficient data precluded meta-analysis on other health-care workers. CONCLUSION: Physicians are an at-risk profession of suicide, with women particularly at risk. The rate of suicide in physicians decreased over time, especially in Europe. The high prevalence of physicians who committed suicide attempt as well as those with suicidal ideation should benefits for preventive strategies at the workplace. Finally, the lack of data on other health-care workers suggest to implement studies investigating those occupations.

2.
Intern Emerg Med ; 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31776841

RESUMO

In the original publication, part of the conflict of statement was incorrectly published as "Dr. Bikdeli reports that he was approached by lawyers on behalf of plaintiffs in litigation related to IVC filters". The correct statement should read as "Dr. Bikdeli reports that he is a consulting expert (on behalf of the plaintiff) for litigation related to a specific type of IVC filters".

3.
Eur J Intern Med ; 68: 30-35, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31427187

RESUMO

BACKGROUND: The clinical outcomes during the course of anticoagulation in patients with venous thromboembolism (VTE) using statins remain controversial. METHODS: We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to compare the risk for VTE recurrences, major bleeding or death during anticoagulation, according to the use of statins at baseline. We used propensity score-matching (PSM) to adjust for confounding variables. RESULTS: From February 2009 to January 2018, 32,062 VTE patients were included. Of these, 7,085 (22%) were using statins. Statin users were 10 years older (73±11 vs. 63±19 years, respectively) and more likely to have comorbidities or to be using antiplatelets or corticosteroids at baseline than non-users. During the course of anticoagulation (median, 177 days), 694 patients developed VTE recurrences, 848 bled and 3,169 died (fatal pulmonary embolism 176, fatal bleeding 121). Statin users had a similar rate of VTE recurrences (hazard ratio [HR]: 0.98; 95%CI: 0.82-1.17), a higher rate of major bleeding (HR: 1.29; 95%CI: 1.11-1.50) and a similar mortality rate (HR: 1.01; 95%CI: 0.93-1.10) than non-users. On PSM analysis, statin users had a significantly lower risk for death (HR: 0.62; 95%CI: 0.48-0.79) and a similar risk for VTE recurrences (HR: 0.98; 95%CI: 0.61-1.57) or major bleeding (HR: 0.85; 95%CI: 0.59-1.21) than non-users. CONCLUSIONS: During anticoagulation for VTE, patients using statins at baseline had a lower risk to die than non-users.

5.
Intern Emerg Med ; 14(7): 1101-1112, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31054013

RESUMO

The association between inferior vena cava filter (IVC) use and outcome in patients presenting with major bleeding during anticoagulation for venous thromboembolism (VTE) has not been thoroughly investigated. We used the RIETE registry to compare the 30-day outcomes (death, major re-bleeding or VTE recurrences) in VTE patients who bled during the first 3 months of therapy, regarding the insertion of an IVC filter. A propensity score matched (PSM) analysis was performed to adjust for potential confounders. From January 2001 to September 2016, 1065 VTE patients had major bleeding during the first 3 months of anticoagulation (gastrointestinal 370; intracranial 124). Of these, 122 patients (11%) received an IVC filter. Patients receiving a filter restarted anticoagulation later (median, 4 vs. 2 days) and at lower doses (95 ± 52 IU/kg/day vs. 104 ± 55 of low-molecular-weight heparin) than those not receiving a filter. During the first 30 days after bleeding (after excluding 246 patients who died within the first 24 h), 283 patients (27%) died, 63 (5.9%) had non-fatal re-bleeding and 19 (1.8%) had recurrent pulmonary embolism (PE). In PSM analysis, patients receiving an IVC filter (n = 122) had a lower risk for all-cause death (HR 0.49; 95% CI 0.31-0.77) or fatal bleeding (HR 0.16; 95% CI 0.07-0.49) and a similar risk for re-bleeding (HR 0.55; 95% CI 0.23-1.40) or PE recurrences (HR 1.57; 95% CI 0.38-6.36) than those not receiving a filter (n = 429). In VTE patients experiencing major bleeding during the first 3 months, use of an IVC filter was associated with reduced mortality rates.Clinical Trial Registration NCT02832245.

6.
Ann Emerg Med ; 74(4): 580-591, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30982631

RESUMO

STUDY OBJECTIVE: Efforts to reduce unnecessary and unnecessarily long antibiotic treatment for community-acquired pneumonia have been attempted through use of procalcitonin and through guidelines based on serial clinical assessment. Our aim is to compare guideline-based clinical assessment- and procalcitonin algorithm-guided antibiotic use among patients with community-acquired pneumonia. METHODS: We performed a pragmatic, randomized, multicenter trial from November 2012 to April 2015 at 12 French hospitals. We included emergency department (ED) patients older than 18 years with community-acquired pneumonia. Patients were randomly assigned to either the procalcitonin-guided or clinical assessment group. In accordance with past studies, we hypothesized that serial clinical assessment would be superior to procalcitonin-guided care. The primary outcome was antibiotic duration, and secondary outcomes included rates of antibiotic duration less than or equal to 5 days, and clinical success and combined serious adverse outcomes at 30 days in the intention-to-treat population. RESULTS: Of 370 eligible patients, 285 (77%) were randomly assigned to either clinical assessment- (n=143) or procalcitonin-guided care (n=142). Median age was 67 years (range 18 to 93 years) and 40% of patients were deemed to have Pneumonia Severity Index class IV or V. Procalcitonin algorithm adherence was 76%. Antibiotic duration was not significantly different between clinical assessment- and procalcitonin-guided groups (median 9 versus 10 days, respectively). Clinical success rate was 92% in each group and serious adverse outcome rates were similar (15% versus 20%, respectively). CONCLUSION: Guideline-based serial clinical assessment did not reduce antibiotic exposure compared with procalcitonin-guided care among ED patients with community-acquired pneumonia. The strategies were similar in terms of duration of antibiotic use and clinical outcomes.

8.
Thromb Res ; 171: 74-80, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30265883

RESUMO

BACKGROUND: The optimal management of major bleeding in patients receiving vitamin K antagonists (VKA) for venous thromboembolism (VTE) is unclear. METHODS: We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the management and 30-day outcomes after major bleeding in patients receiving VKA for VTE. RESULTS: From January 2013 to December 2017, 267 of 18,416 patients (1.4%) receiving long-term VKA for VTE had a major bleeding (in the gastrointestinal tract 78, intracranial 72, hematoma 50, genitourinary 20, other 47). Overall, 151 patients (57%) received blood transfusion; 110 (41%) vitamin K; 37 (14%) fresh frozen plasma; 29 (11%) pro-haemostatic agents and 20 (7.5%) a vena cava filter. During the first 30 days, 59 patients (22%) died (41 died of bleeding) and 13 (4.9%) had a thrombosis. On multivariable analysis, patients with intracranial bleeding (hazard ratio [HR]: 4.58; 95%CI: 2.40-8.72) and those with renal insufficiency at baseline (HR: 2.73; 95%CI: 1.45-5.15) had an increased mortality risk, whereas those receiving vitamin K had a lower risk (HR: 0.47; 0.24-0.92). On the other hand, patients receiving fresh frozen plasma were at increased risk for thrombotic events (HR: 4.22; 95%CI: 1.25-14.3). CONCLUSIONS: Major bleeding in VTE patients receiving VKA carries a high mortality rate. Intracranial bleeding and renal insufficiency increased the risk. Fresh frozen plasma seems to increase this risk for recurrent VTE.


Assuntos
Anticoagulantes/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/terapia , Tromboembolia Venosa/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/métodos , Feminino , Hemorragia/mortalidade , Hemostáticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/complicações , Estudos Retrospectivos , Resultado do Tratamento , Tromboembolia Venosa/complicações , Vitamina K/uso terapêutico
9.
Clin Chem Lab Med ; 56(11): 1897-1904, 2018 10 25.
Artigo em Inglês | MEDLINE | ID: mdl-29924734

RESUMO

BACKGROUND: This study's primary objective was to validate the routine use of S100B via a prospective study. The aim was a reduction of cranial computed tomography (CCT) scans by 30%. The secondary goal was to investigate the influence of age and associated risk factors on the reduction of CCT. METHODS: S100B (sampling within 3 h postinjury) was used for patients with mild traumatic brain injury (mTBIs) presenting a medium risk of complications and requiring a CCT scan. Patients with negative S100B (S100B-) were discharged without a CCT scan. RESULTS: Of the 1449 patients included in this study, 468 (32.3%) had S100B- with a sensitivity of 96.4% (95% CI: 87.5%-99.6%), a specificity of 33.4% (95% CI: 31%-36%) and a negative predictive value of 99.6% (95% CI: 98.5%-99.9%). No significant difference in serum levels or the S100B+ rate was observed if patients had retrograde amnesia (0.16 µg/L; 63.8%), loss of consciousness (0.13; 63.6%) or antiplatelet therapy (0.20; 77.9%). Significant differences were found between the S100B concentrations and S100B positivity rates in patients >65 years old and all the groups with patients <55 years old (18-25, 26-35, 36-45 and 46-55). From 18 to 65 years old (n=874), the specificity is 39.3% (95% CI: 36%-42.6%) compared to 18.7% (95% CI: 15.3%-22.3%) for patients >65 years old (n=504). CONCLUSIONS: The clinical use of S100B in mTBI management reduces the use of CCTs by approximately one-third; furthermore, the percentage of CCTs reduction is influenced by the age of the patient.


Assuntos
Lesões Encefálicas/diagnóstico , Subunidade beta da Proteína Ligante de Cálcio S100/sangue , Adolescente , Adulto , Fatores Etários , Idoso , Consumo de Bebidas Alcoólicas , Biomarcadores/sangue , Lesões Encefálicas/patologia , Estudos de Coortes , Humanos , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Adulto Jovem
10.
Scand J Trauma Resusc Emerg Med ; 26(1): 50, 2018 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-29914560

RESUMO

BACKGROUND: In head trauma cases involving antiplatelet agent treatment, the French Society of Emergency Medicine recommends performing computed tomography (CT) scans to detect brain lesions, 90% of which are normal. The value of CT is still debatable given the scarce number of studies and controversial results. METHODS: We used the RATED registry (Registry of patient with Antithrombotic agents admitted to an Emergency Department, NCT02706080) to assess factors of cerebral bleeding related to antiplatelet agents following head trauma. RESULTS: From January 2014 to December 2015, 993 patients receiving antiplatelet agents were recruited, 293 (29.5%) of whom underwent CT scans for brain trauma. Intracranial bleeding was found in 26 (8.9%). Multivariate analysis revealed these patients more likely to have a history of severe hemorrhage (odds ratio [OR]: 8.47, 95% confidence interval [CI]: 1.56-45.82), dual antiplatelet therapy (OR: 6.46, 95%CI:1.46-28.44), headache or vomiting (OR: 4.27, 95%CI: 1.44-2.60), and abnormal Glasgow coma scale (OR: 8.60; 95%CI: 2.85-25.99) compared to those without intracranial bleeding. The predictive model derived from these variables achieved 98.9% specificity and a negative predictive value of 92%. The area under the ROC curve (AUROC) was 0.85 (95%CI: 0.77-0.93). CONCLUSIONS: Our study demonstrated that the absence of history of severe hemorrhage, dual antiplatelet therapy, headache or vomiting, and abnormal Glasgow coma scale score appears to predict normal CT scan following traumatic brain injury in patients taking antiplatelets. This finding requires confirmation by prospective studies. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT02706080 .


Assuntos
Traumatismos Craniocerebrais/fisiopatologia , Serviço Hospitalar de Emergência , Hemorragias Intracranianas , Inibidores da Agregação de Plaquetas/administração & dosagem , Idoso , Feminino , Escala de Coma de Glasgow , Hospitalização , Humanos , Masculino , Análise Multivariada , Estudos Prospectivos , Sistema de Registros , Tomografia Computadorizada por Raios X
11.
JMIR Ment Health ; 5(1): e12, 2018 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-29439945

RESUMO

BACKGROUND: Work addiction is a significant public health problem with a growing prevalence. The Work Addiction Risk Test (WART) is the gold standard questionnaire to detect workaholism. OBJECTIVE: The main objective of this study was to validate the French version of the WART. METHODS: Questionnaires were proposed to voluntary French workers using the WittyFit software. There were no exclusion criteria. The questionnaire was administered anonymously for initial validity testing and readministered one week later for test-retest reliability. We also assessed the workers' sociodemographic characteristics, as well as other measurements for external validity, such as stress, well-being, and coaddictions to tobacco, alcohol, and cannabis. Several psychometric properties of the French-WART were explored: acceptability, reliability (internal consistency [Cronbach alpha coefficient] and reproducibility [Lin concordance coefficient]), construct validity (correlation coefficients and principal component analysis), and external validity (correlation coefficients). RESULTS: Among the 1580 workers using WittyFit, 187 (11.83%) agreed to complete the WART questionnaire. Of those, 128 completed the test-retest survey (68.4%). Acceptability found that all respondents had fully completed the questionnaire, with few floor or ceiling effects. Reliability was very good with a Cronbach alpha coefficient at .90 (internal consistency) and Lin concordance coefficient at .90 (95% CI .87-.94] with a difference on the retest of .04 (SD 4.9) (95% CI -9.6 to 9.7) (reproducibility). We identified three main dimensions (construct validity). Relationships between WART and stress and well-being confirmed its external validity. CONCLUSIONS: The French version of the WART is a valid and reliable instrument to assess work addiction with satisfactory psychometric properties. Used in occupational medicine, this tool would allow the diagnosis of work addiction and can be easily implemented in current practice.

12.
Clin Pharmacol Ther ; 103(4): 684-691, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28675460

RESUMO

We assessed the real-life use of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and exclusion criteria for randomized trials. From 2013 to 2016, 3,578 of 18,853 patients (19%) had exclusion criteria. Irrespective of which anticoagulant was chosen, they had more VTE recurrences (hazard ratio (HR): 3.10; 95% confidence interval (CI): 2.47-3.88), major bleeds (HR: 4.10; 95% CI: 3.38-4.96), and deaths (HR: 9.47; 95% CI: 8.46-10.6) than those without exclusion criteria. During initial therapy, no patient with exclusion criteria on DOACs (n = 115) recurred, but those on rivaroxaban bled less often (adjusted HR: 0.18; 95% CI: 0.04-0.79) than those on unfractionated heparin (n = 224) and similar to those (n = 3,172) on low-molecular-weight (LMWH) heparin. For long-term therapy, patients on rivaroxaban (n = 151) had nonsignificantly fewer VTE recurrences (adjusted HR: 0.74; 95% CI: 0.08-1.32) and major bleeds (adjusted HR: 0.41; 95% CI: 0.15-1.15) than those on LMWH (n = 2,071). The efficacy and safety of DOACs were similar to standard therapy.


Assuntos
Hemorragia/diagnóstico , Seleção de Pacientes , Rivaroxabana , Tromboembolia Venosa/tratamento farmacológico , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/classificação , Inibidores do Fator Xa/administração & dosagem , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/farmacocinética , Feminino , Hemorragia/induzido quimicamente , Heparina/administração & dosagem , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Efeitos Adversos de Longa Duração/induzido quimicamente , Efeitos Adversos de Longa Duração/diagnóstico , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Rivaroxabana/farmacocinética , Resultado do Tratamento , Tromboembolia Venosa/mortalidade
13.
Lancet Haematol ; 4(12): e615-e621, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29150390

RESUMO

BACKGROUND: The ability of the pulmonary embolism rule-out criteria (PERC) to exclude pulmonary embolism without further testing remains debated outside the USA, especially in the population with suspected pulmonary embolism who have a high prevalence of the condition. Our main objective was to prospectively assess the predictive value of negative PERC to rule out pulmonary embolism among European patients with low implicit clinical probability. METHODS: We did a multicentre, prospective, observational study in 12 emergency departments in France and Belgium. We included consecutive patients aged 18 years or older with suspected pulmonary embolism. Patients were excluded if they had already been hospitalised for more than 2 days, had curative anticoagulant therapy in progress for more than 48 h, or had a diagnosis of thromboembolic disease documented before admission to emergency department. Physicians completed a standardised case report form comprising implicit clinical probability assessment (low, moderate, or high) and a list of risk factors including criteria of the PERC rule. They were asked to follow international recommendations for diagnostic strategy, masked to PERC assessment. The primary endpoint was the proportion of patients with low implicit clinical probability and negative PERC who had venous thromboembolic events, diagnosed during initial diagnostic work-up or during 3-month follow-up, as externally adjudicated by an independent committee masked to the PERC and clinical probability assessment. The upper limit of the 95% CI around the 3-month thromboembolic risk was set at 3%. We did all analyses by intention to treat, including all patients with complete follow-up. This trial is registered with ClinicalTrials.gov, number NCT02360540. FINDINGS: Between May 1, 2015, and April 30, 2016, 1773 consecutive patients with suspected pulmonary embolism were prospectively assessed for inclusion, of whom 1757 were included. 1052 (60%) patients were classed as having low clinical probability, 49 (4·7%, 95% CI 3·5-6·1) of whom had a venous thromboembolic event. In patients with a low implicit clinical probability, 337 (32%) patients had negative PERC, of whom four (1·2%; 95% CI 0·4-2·9) went on to have a pulmonary embolism. INTERPRETATION: In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results. The results of our prospective, observational study allow and justify an implementation study of the PERC rule in Europe. FUNDING: French Ministry of Health.


Assuntos
Embolia Pulmonar/diagnóstico , Adulto , Idoso , Angiografia , Anticoagulantes/uso terapêutico , Serviço Hospitalar de Emergência , Grupo com Ancestrais do Continente Europeu , Reações Falso-Negativas , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/tratamento farmacológico , Fatores de Risco , Resultado do Tratamento , Ultrassonografia
14.
BMJ Open ; 7(9): e016238, 2017 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-28939575

RESUMO

OBJECTIVES: To demonstrate that urine cytology screening can provide relevant epidemiological data for earlier detection of urothelial cancer caused by occupational exposure. DESIGN: Prospective cohort study. SETTING: Industries using urothelial carcinogens in France. Urine samples were collected on site, after a work week and were analysed at the University Hospital of Clermont-Ferrand, France. PARTICIPANTS: Participants were workers exposed to urothelial carcinogens. Women and current smokers at time of study recruitment were exclusion criteria. OUTCOMES: Urine cells atypia were ranged into three classes: negative/normal, atypical/suspicious/dysplasia or positive/malignant. RESULTS: We included 2020 workers over a period of 20 years from 1993 to 2013: 606 worked in rubber manufacturing, 692 from metal processing, 245 in chemical industry and 477 in roadwork and building industry. Workers had a mean exposure of 15.2±10.4 years before their first urine cytology screening. There was a mean of 3.4±4.3 urine cytology screenings per worker between 1993 and 2013. 6478 cytology were normal, 462 suspicious and 13 malignant. Suspicious and malignant cytology occurred in 4.8% of workers exposed for 1-10 years, 6.2% for 11-20 years of exposure, 7.6% for 21-30 years and 8.6% for >30 years (p<0.001). Using exposure for 1-10 years as reference, the adjusted OR of receiving a suspicious or malignant diagnosis increased with duration of exposure: OR=1.50 (95% CI 1.10 to 2.05, p=0.01) for 21-30 years and OR=1.78 (95% CI 1.23 to 2.56, p=0.002) for >30 years of exposure. Using metal processing as reference, the risk of pathological urine cytology results increased for rubber manufacturing (OR=1.32, 95% CI 1.05 to 1.65, p=0.02), with a trend for roadwork and building industry (OR=1.39, 95% CI 0.98 to 1.97, p=0.07) and for chemical industry (OR=1.34, 95% CI 0.94 to 1.93, p=0.11). CONCLUSIONS: Urine cytology is a useful tool in occupational medicine. We promote new guidelines with an early screening of urothelial cancer by cytology, starting with beginning of exposure.


Assuntos
Detecção Precoce de Câncer/métodos , Indústria Manufatureira/estatística & dados numéricos , Exposição Ocupacional/estatística & dados numéricos , Urina/citologia , Neoplasias Urológicas/diagnóstico , Neoplasias Urológicas/epidemiologia , Adulto , Feminino , França/epidemiologia , Humanos , Modelos Logísticos , Masculino , Indústria Manufatureira/classificação , Pessoa de Meia-Idade , Análise Multivariada , Exposição Ocupacional/análise , Estudos Prospectivos , Fatores de Tempo
15.
Clin Drug Investig ; 37(10): 929-936, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28612237

RESUMO

BACKGROUND: Several studies have suggested a link exists between L-thyroxine and the coagulation system, and, according to some drug interaction studies, L-thyroxine can potentiate the effect of warfarin. This study sought to assess whether thyroid hormone therapy could impact the risk of bleeding in patients receiving vitamin K antagonists (VKAs). METHODS: We conducted a monocentric, retrospective study on prospectively collected data from consecutive patients enrolled in the Registry of patient with AntiThrombotic agents admitted to an Emergency Department (RATED) database, and compared the hemorrhage rates (both major and nonmajor) of patients receiving treatment with and without L-thyroxine. Propensity score matching analysis was performed to reduce the differences between patients receiving L-thyroxine and those not receiving L-thyroxine in order to reassess bleeding outcomes in patients receiving VKAs. RESULTS: From January 2014 to June 2015, 1454 patients receiving VKAs were recruited into the RATED database. Overall, 187 patients (12.8%) received L-thyroxine. Patients receiving L-thyroxine were more likely to be female than those not receiving L-thyroxine (78.1 vs. 55%) and more likely to exhibit hypertension (65.5 vs. 55.7%; p = 0.015), but less likely to have history of myocardial infarction (9.6 vs. 16.6%; p = 0.022) or higher creatinine levels (96.1 vs. 112.1 µmol/L; p = 0.04). After propensity score matching, bleeding outcomes were not significantly different between patients receiving L-thyroxine and those not receiving L-thyroxine. CONCLUSIONS: Our study revealed no evidence that L-thyroxine could increase bleeding risk in patients receiving VKAs. However, physicians must be aware that patients with thyroid disease receiving VKA therapy could have other drug interactions, particularly with amiodarone therapy. CLINICALTRIALS. GOV NUMBER: NCT02706080.


Assuntos
Anticoagulantes/uso terapêutico , Hemorragia/induzido quimicamente , Tiroxina/uso terapêutico , Vitamina K/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Estudos Retrospectivos , Varfarina/uso terapêutico
16.
PLoS One ; 12(6): e0178948, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28586383

RESUMO

BACKGROUND: The visual analogue scale (VAS) is widely used in clinical practice by occupational physicians to assess perceived stress in workers. However, a single cut-off (black-or-white decision) inadequately discriminates between workers with and without stress. We explored an innovative statistical approach to distinguish an at-risk population among stressed workers, and to establish a threshold over which an action is urgently required, via the use of two cut-offs. METHODS: Participants were recruited during annual work medical examinations by a random sample of workers from five occupational health centres. We previously proposed a single cut-off of VAS stress in comparison with the Perceived Stress Scale (PSS14). Similar methodology was used in the current study, along with a gray zone approach. The lower limit of the gray zone supports sensitivity ("at-risk" threshold; interpreted as requiring closer surveillance) and the upper limit supports specificity (i.e. "intervention" threshold-emergency action required). RESULTS: We included 500 workers (49.6% males), aged 40±11 years, with a PSS14 score of 3.8±1.4 and a VAS score of 4.0±2.4. Using a receiver operating characteristic curve and the PSS cut-off score of 7.2, the optimal VAS threshold was 6.8 (sensitivity = 0.89, specificity = 0.87). The lower and upper thresholds of the gray zone were 5 and 8.2, respectively. CONCLUSIONS: We identified two clinically relevant cut-offs on the VAS of stress: a first cut-off of 5.0 for an at-risk population, and a second cut-off of 8.2 over which an action is urgently required. Future investigations into the relationships between this upper threshold and deleterious events are required.


Assuntos
Emprego/psicologia , Estresse Psicológico/psicologia , Escala Visual Analógica , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estresse Psicológico/fisiopatologia , Inquéritos e Questionários
17.
Drug Alcohol Depend ; 175: 92-98, 2017 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-28411560

RESUMO

BACKGROUND: Binge drinking (BD) consists of heavy episodic alcohol use. Whereas the World Health Organization (WHO) defines BD as 60g of alcohol or more per occasion, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) conceives BD as drinking 70g (men) or 56g (women) in less than two hours. We compared the subjects delineated by each definition. METHODS: Eight-center cross-sectional study among 11,695 subjects hospitalized in emergency wards. Participants completed the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C), CAGE and Rapid Alcohol Problem Screen 4 (RAPS4-QF) questionnaires. The WHO criteria were investigated using the RAPS4-QF. Independent questions assessed the NIAAA criteria. The main medical admission motive was noted. The characteristics of subjects meeting respectively: 1) the exclusive WHO criteria (BD1); 2) the NIAAA criteria (BD2); and 3) no BD criteria (noBD) were compared using multinomial regression analyses. Binary age- and gender-adjusted regression analyses directly compared BD1 and BD2. Subjects with at least four drinking occasions per week were excluded from the analyses, to withdrawn regular heavy drinking. RESULTS: Compared to BD1, BD2 subjects were more frequently males (OR=1.67 [1.39-2.0]), single (aOR=1.64 [1.36-1.98]) and unemployed (aOR=1.57 [1.27-1.90]). BD2 reported significantly more drinks per occasion, and higher heavy drinking frequencies. Previous alcohol-related remarks from family (aOR=3.00 [2.53-3.56]), ever drinking on waking-up (aOR=2.05 [1.37-2.72]), and admission for psychiatric motive (aOR=2.27 [1.68-3.07]) were more frequent among BD2 subjects. CONCLUSIONS: Compared to WHO criteria, NIAAA criteria for BD delineate subjects with more concerning drinking patterns and alcohol aftermaths.


Assuntos
Consumo de Bebidas Alcoólicas/epidemiologia , Bebedeira/classificação , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adulto , Consumo de Bebidas Alcoólicas/efeitos adversos , Bebedeira/diagnóstico , Estudos Transversais , Feminino , França/epidemiologia , Humanos , Masculino , National Institute on Alcohol Abuse and Alcoholism (U.S.)/normas , Valores de Referência , Análise de Regressão , Inquéritos e Questionários , Estados Unidos , Organização Mundial da Saúde
18.
Thromb Res ; 151 Suppl 1: S1-S5, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28262225

RESUMO

BACKGROUND: Women presenting with uterine bleeding during the course of anticoagulant therapy for venous thromboembolism (VTE) present a difficult therapeutic dilemma due to the absence of evidence-based recommendations. METHODS: We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to assess the clinical characteristics of women presenting with uterine bleeding during anticoagulation for VTE, its frequency, time course, management and 30-day outcomes. RESULTS: As of October 2016, 31,951 women with VTE were recruited in RIETE. During the course of anticoagulant therapy, 53 (0.17%) developed major uterine bleeding, 118 (0.37%) non-major uterine bleeding and 948 (2.97%) had major bleeding in other sites. Median time elapsed from VTE to bleeding was: 32, 71 and 22 days, respectively. Mean age was: 56±17, 52±20 and 75±14 years, respectively. Women with major uterine bleeding more likely had cancer (51%), anemia (72%), raised platelet count (19%) or recent major bleeding (11%) at VTE presentation than those in the other subgroups. During the first 30 days after bleeding, 17%, 1.7% and 31% of women died, respectively. Of 11 women with uterine bleeding who died, 9 (82%) had cancer, two (18%) died of bleeding and one (9.1%) died of pulmonary embolism after discontinuing anticoagulation. CONCLUSIONS: Uterine bleeding during the course of anticoagulation for VTE is not uncommon and mostly affects young women. Those with cancer, anaemia, raised platelet count or recent bleeding at baseline are at an increased risk for uterine bleeding during anticoagulation.


Assuntos
Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Hemorragia Uterina/induzido quimicamente , Tromboembolia Venosa/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias/complicações , Estudos Retrospectivos , Tromboembolia Venosa/complicações
19.
Int Arch Occup Environ Health ; 90(6): 467-480, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28271382

RESUMO

PURPOSE: To compare tachycardia and cardiac strain between 24-hour shifts (24hS) and 14-hour night shifts (14hS) in emergency physicians (EPs), and to investigate key factors influencing tachycardia and cardiac strain. METHODS: We monitored heart rate (HR) with Holter-ECG in a shift-randomized trial comparing a 24hS, a 14hS, and a control day, within a potential for 19 EPs. We also measured 24-h HR the third day (D3) after both shifts. We measured perceived stress by visual analog scale and the number of life-and-death emergencies. RESULTS: The 17 EPs completing the whole protocol reached maximal HR (180.9 ± 6.9 bpm) during both shifts. Minutes of tachycardia >100 bpm were higher in 24hS (208.3 ± 63.8) than in any other days (14hS: 142.3 ± 36.9; D3/14hS: 64.8 ± 31.4; D3/24hS: 57.6 ± 19.1; control day: 39.2 ± 11.6 min, p < .05). Shifts induced a cardiac strain twice higher than in days not involving patients contact. Each life-and-death emergency enhanced 26 min of tachycardia ≥100 bpm (p < .001), 7 min ≥ 110 bpm (p < .001), 2 min ≥ 120 bpm (p < .001) and 19 min of cardiac strain ≥30% (p = .014). Stress was associated with greater duration of tachycardia ≥100, 110 and 120 bpm, and of cardiac strain ≥30% (p < .001). CONCLUSION: We demonstrated several incidences of maximal HR during shifts combined with a high cardiac strain. Duration of tachycardia were the highest in 24hS and lasted several hours. Such values are comparable to those of workers exposed to high physical demanding tasks or heat. Therefore, we suggest that EPs limit their exposure to 24hS. We, furthermore, demonstrated benefits of HR monitoring for identifying stressful events. ClinicalTrials.gov identifier: NCT01874704.


Assuntos
Medicina de Emergência , Exposição Ocupacional/efeitos adversos , Médicos/psicologia , Jornada de Trabalho em Turnos/efeitos adversos , Estresse Psicológico/complicações , Taquicardia/psicologia , Adulto , Índice de Massa Corporal , Feminino , França , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Ambulatorial , Análise Multivariada , Fatores de Risco , Transtornos do Sono do Ritmo Circadiano , Estresse Fisiológico , Inquéritos e Questionários , Escala Visual Analógica , Tolerância ao Trabalho Programado/fisiologia
20.
Res Pract Thromb Haemost ; 1(2): 172-179, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30046687

RESUMO

Background: Subgroup analyses from randomized trials suggested favorable results for the direct oral anticoagulants in fragile patients with venous thromboembolism (VTE). The frequency and natural history of fragile patients with VTE have not been studied yet. Objectives: To compare the clinical characteristics, treatment and outcomes during the first 3 months of anticoagulation in fragile vs non-fragile patients with VTE. Methods: Retrospective study using consecutive patients enrolled in the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry. Fragile patients were defined as those having age ≥75 years, creatinine clearance (CrCl) levels ≤50 mL/min, and/or body weight ≤50 kg. Results: From January 2013 to October 2016, 15 079 patients were recruited. Of these, 6260 (42%) were fragile: 37% were aged ≥75 years, 20% had CrCl levels ≤50 mL/min, and 3.6% weighed ≤50 kg. During the first 3 months of anticoagulant therapy, fragile patients had a lower risk of VTE recurrences (0.78% vs 1.4%; adjusted odds ratio [OR]: 0.52; 95% confidence intervals [CI]: 0.37-0.74) and a higher risk of major bleeding (2.6% vs 1.4%; adjusted OR: 1.41; 95% CI: 1.10-1.80), gastrointestinal bleeding (0.86% vs 0.35%; adjusted OR: 1.84; 95% CI: 1.16-2.92), haematoma (0.51% vs 0.07%; adjusted OR: 5.05; 95% CI: 2.05-12.4), all-cause death (9.2% vs 3.5%; adjusted OR: 2.02; 95% CI: 1.75-2.33), or fatal PE (0.85% vs 0.35%; adjusted OR: 1.77; 95% CI: 1.10-2.85) than the non-fragile. Conclusions: In real life, 42% of VTE patients were fragile. During anticoagulation, they had fewer VTE recurrences and more major bleeding events than the non-fragile.

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