Acetylcysteine for prevention of contrast-induced nephropathy after intravascular angiography: A systematic review and meta-analysis

BACKGROUND: Contrast-induced nephropathy is an important cause of acute renal failure. We assess the efficacy of acetylcysteine for prevention of contrast-induced nephropathy among patients undergoing intravascular angiography. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials comparing prophylactic acetylcysteine plus hydration versus hydration alone in patients undergoing intravascular angiography. Studies were identified by searching MEDLINE, EMBASE, and CENTRAL databases. Our main outcome measures were the risk of contrast-induced nephropathy and the difference in serum creatinine between acetylcysteine and control groups at 48 h. RESULTS: Fourteen studies involving 1261 patients were identified and included for analysis, and findings were heterogeneous across studies. Acetylcysteine was associated with a significantly reduced incidence of contrast-induced nephropathy in five studies, and no difference in the other nine (with a trend toward a higher incidence in six of the latter studies). The pooled odds ratio for contrast-induced nephropathy with acetylcysteine relative to control was 0.54 (95% CI, 0.32–0.91, p = 0.02) and the pooled estimate of difference in 48-h serum creatinine for acetylcysteine relative to control was -7.2 μmol/L (95% CI -19.7 to 5.3, p = 0.26). These pooled values need to be interpreted cautiously because of the heterogeneity across studies, and due to evidence of publication bias. Meta-regression suggested that the heterogeneity might be partially explained by whether the angiography was performed electively or as emergency. CONCLUSION: These findings indicate that published studies of acetylcysteine for prevention of contrast-induced nephropathy yield inconsistent results. The efficacy of acetylcysteine will remain uncertain unless a large well-designed multi-center trial is performed

Consultation patterns and clinical correlates of consultation in a tertiary care setting

<p>Abstract</p> <p>Background</p> <p>Consultation in hospital is an essential tool for acquiring subspecialty support when managing patients. There is limited knowledge on the utilization of subspecialty consultation from hospital based general internists. Consultation patterns to medical subspecialists and the patient factors that may influence consultation are reported for general medical services.</p> <p>Methods and findings</p> <p>Hospital discharge data were obtained for patients from medical services over a 2-year period. Consultations requested to medicine subspecialties were identified, and then reported by type and frequency. Information on demographic factors, clinical diagnoses, length of stay (LOS), time in critical care units, and disposition were compared for patients with and without consultation.</p> <p>3979 patients were hospitalized during the study and 2885 consultations occurred. Almost half of the patients received at least one consultation (48.3%). Gastroenterology (26.3%), infectious diseases (14.6%) and respirology (13.6%) were the most frequently consulted services. Patients with consultation had a greater number of total diagnoses (7.3 vs. 5.5, P < 0.001), a greater mean LOS (15.9 vs. 6.8 days), were more likely to spend time in the ICU (11.5% vs. 3.5%) and CCU (4.3% vs. 1.2%), and to expire in hospital (10.7% vs. 4.9%).</p> <p>Conclusion</p> <p>Consultation occurs frequently and its presence is an indicator of patient complexity and high use of health system resources. Analysis of consultation patterns for specific patient populations could assist in optimizing efficiency in health care delivery. Targeting quality improvement strategies toward optimizing consultation processes, engaging heavily utilized subspecialties in educational roles and assisting with resource planning are areas for future consideration.</p

Determining geographic areas and populations with timely access to cardiac catheterization facilities for acute myocardial infarction care in Alberta, Canada

<p>Abstract</p> <p>Background</p> <p>This study uses geographic information systems (GIS) as a tool to evaluate and visualize the general accessibility of areas within the province of Alberta (Canada) to cardiac catheterization facilities. Current American and European guidelines suggest performing catheterization within 90 minutes of the first medical contact. For this reason, this study evaluates the populated places that are within a 90 minute transfer time to a city with a catheterization facility. The three modes of transport considered in this study are ground ambulance, rotary wing air ambulance and fixed wing air ambulance.</p> <p>Methods</p> <p>Reference data from the Alberta Chart of Call were interpolated into continuous travel time surfaces. These continuous surfaces allowed for the delineation of isochrones: lines that connect areas of equal time. Using Dissemination Area (DA) centroids to represent the adult population, the population numbers were extracted from the isochrones using Statistics Canada census data.</p> <p>Results</p> <p>By extracting the adult population from within isochrones for each emergency transport mode analyzed, it was found that roughly 70% of the adult population of Alberta had access within 90 minutes to catheterization facilities by ground, roughly 66% of the adult population had access by rotary wing air ambulance and that no population had access within 90 minutes using the fixed wing air ambulance. An overall understanding of the nature of air vs. ground emergency travel was also uncovered; zones were revealed where the use of one mode would be faster than the others for reaching a facility.</p> <p>Conclusion</p> <p>Catheter intervention for acute myocardial infarction is a time sensitive procedure. This study revealed that although a relatively small area of the province had access within the 90 minute time constraint, this area represented a large proportion of the population. Within Alberta, fixed wing air ambulance is not an effective means of transporting patients to a catheterization facility within the 90 minute time frame, though it becomes advantageous as a means of transportation for larger distances when there is less urgency.</p

The International Population Data Linkage Network – Banff and Beyond

We write to you, here in the pages of the International Journal of Population Data Science, for the second time in our capacity of co-directors of the International Population Data Linkage Network (IPDLN – www.ipdln.org). Time has certainly passed quickly since our first communication, where we introduced ourselves, and discussed planned initiatives for our tenure as leads of the IPDLN. Our network’s scientific community is steadily growing and thriving in an era of heightened interest around all things ‘data’. Indeed, there is great enthusiasm for all initiatives that explore ways of harnessing information systems and multisource data to enhance collective knowledge of health matters so that better decisions can be made by governments, system planners, providers, and patients. Never before have such initiatives attracted more attention. It is in this context of heightened interest and relevance around IPDLN and its science that we prepare to convene in Banff, Alberta, Canada for the 5th biennial IPDLN Conference – September 11-14. The conference, to be held at the inspiring Banff Centre (www.banffcentre.ca), is almost sold out, with only limited space remaining for late registrants. A tremendous program has been created through the oversight of Scientific Program co-chairs, Drs. Astrid Guttman and Hude Quan. A compelling roster of plenary lectures from Drs. Diane Watson, Jennifer Walker, and Osmar Zaïane is eagerly anticipated, as are topical panel discussions, an entertaining Science Slam session, and a terrific social program. These sessions will be surrounded by rich scientific oral and poster presentations arising from the more than 450 scientific abstracts submitted for review. We are so pleased to see this vibrant scientific engagement from the IPDLN membership and students, and look forward to hosting all delegates in Banff. The Banff conference will also be the venue at which we announce the new Directorship of the IPDLN for the next two years (2019 and 2020). As co-directors, we engaged with a number of individuals and organizations with interest in leading the IPDLN. In the end, two compelling Directorship applications were submitted – one a joint bid from Australia’s Population Health Research Network and the South Australia Northern Territory DataLink, and the other from the US-based Actionable Intelligence for Social Policy. IPDLN members submitted votes on these strong leadership bids through an online voting process, and while the excellence and appeal of both bids was apparent in strong voter support for both, a winning bid has been confirmed, and it will (as mentioned) be announced at the upcoming September conference. As we look forward to the Banff meeting with great anticipation, we are compelled to acknowledge the growing IPDLN legacy created by past directors. We are particularly indebted to our immediate predecessor, Dr. David Ford, and his team at Swansea University. Their work in hosting the 2016 IPDLN conference has been an inspiration to us in the planning of this year’s conference, and their crucial and foundational work in creating an IT platform for the IPDLN website, the membership database, and the new International Journal for Population Data Science has brought the IPDLN to a new level of organizational sophistication. Over the last 18 months, our co-directorship teams from the Institute for Clinical Evaluative Sciences in Ontario and the O’Brien Institute for Public Health at the University of Calgary have built on the foundation established by prior directors to update/enhance the IPDLN website and membership database. The IPDLN has more members than ever before representing a greater number of countries, and we have a more formalized governance structure with the creation of an Executive Committee that will include immediate past-Directors in order to better ensure continuity. A new Executive Committee will be elected by the IPDLN membership following the Banff conference. The waiting is almost over and IPDLN 2018 is upon us! Our scientific domain has never had the prominence or level of anticipation that we currently see. And the IPDLN has grown in its size, vibrancy and scientific scope. The opportunities for us are boundless, and the timing of our upcoming conference could not be better. We are honoured, with our respective organizations, to have had this opportunity to serve as co-directors over the past two years, and look forward to seeing many of you very soon. For those of you who are unable to travel to Canada’s Rocky Mountains this year, we look forward to connecting with you at a later time in the IPDLN’s continuing upward journey

Absence of bias against smokers in access to coronary revascularization after cardiac catheterization

Objective. Many consider smoking to be a personal choice for which individuals should be held accountable. We assessed whether there is any evidence of bias against smokers in cardiac care decision-making by determining whether smokers were as likely as non-smokers to undergo revascularization procedures after cardiac catheterization. Design. Prospective cohort study. Subjects and setting. All patients undergoing cardiac catheterization in Alberta, Canada. Main measures. Patients were categorized as current smokers, former smokers, or never smokers, and then compared for their risk-adjusted likelihood of undergoing revascularization procedures (percutaneous coronary intervention or coronary artery bypass grafting) after cardiac catheterization. Results. Among 20406 patients undergoing catheterization, 25.4% were current smokers at the time of catheterization, 36.6% were former smokers, and 38.0% had never smoked. When compared with never smokers (reference group), the hazard ratio for undergoing any revascularization procedure after catheterization was 0.98 (95% CI 0.93-1.03) for current smokers and 0.98 (0.94-1.03) for former smokers. The hazard ratio for undergoing coronary artery bypass grafting was 1.09 (1.00-1.19) for current smokers and 1.00 (0.93-1.08) for former smokers. For percutaneous coronary intervention, the hazard ratios were 0.93 (0.87-0.99) for current smokers and 1.00 (0.94-1.06) for former smokers. Conclusion. Despite potential for discrimination on the basis of smoking status, current and former smokers undergoing cardiac catheterization in Alberta, Canada were as likely to undergo revascularization procedures as catheterization patients who had never smoke

Evaluation of complication rates after coronary artery bypass surgery using administrative data

Our objectives were (1) to determine if studying hospital complication rates after coronary artery bypass graft (CABG) surgery provides information not available when only mortality is studied, and (2) to reexplore the utility of ICD-9-CM administrative data for CABG outcomes assessment. Using data from Massachusetts, we identified CABG cohorts from 1990 and 1992 to respectively develop and validate multivariate risk adjustment models predicting in-hospital mortality and complications. The resulting models had good discrimination and calibration. In 1992, adjusted hospital complication rates ranged widely from 13.0% to 57.6%, while mortality rates ranged from 1.4% to 6.1%. Hospitals with high complication rates tended to have high mortality (r = 0.74, p = 0.006), but 2 of the 12 hospitals studied ranked quite differently when judged by complications rather than mortality. We conclude that (1) complications after CABG occur frequently and may provide information about hospital quality beyond that obtained from hospital mortality rates, and that (2) administrative data continue to be a promising resource for outcomes research

Interpreting and coding causal relationships for quality and safety using ICD-11

Abstract Many circumstances necessitate judgments regarding causation in health information systems, but these can be tricky in medicine and epidemiology. In this article, we reflect on what the ICD-11 Reference Guide provides on coding for causation and judging when relationships between clinical concepts are causal. Based on the use of different types of codes and the development of a new mechanism for coding potential causal relationships, the ICD-11 provides an in-depth transformation of coding expectations as compared to ICD-10. An essential part of the causal relationship interpretation relies on the presence of “connecting terms,” key elements in assessing the level of certainty regarding a potential relationship and how to proceed in coding a causal relationship using the new ICD-11 coding convention of postcoordination (i.e., clustering of codes). In addition, determining causation involves using documentation from healthcare providers, which is the foundation for coding health information. The coding guidelines and examples (taken from the quality and patient safety domain) presented in this article underline how new ICD-11 features and coding rules will enhance future health information systems and healthcare