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Recurrent ischemic stroke in atrial fibrillation with non-vitamin K antagonist oral anticoagulation.Journal of Clinical Neuroscience :... Jun 2019The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants...
The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for ≥48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke.
Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Cerebral Infarction; Female; Humans; Medication Adherence; Middle Aged; Retrospective Studies; Stroke
PubMed: 30929960
DOI: 10.1016/j.jocn.2019.03.037 -
Radiology Case Reports Jan 2023Clavicle fractures are extremely common, accounting for 5%-10% of all pediatric fractures. Due to the increased radiation dose, additional radiographic views are less...
Clavicle fractures are extremely common, accounting for 5%-10% of all pediatric fractures. Due to the increased radiation dose, additional radiographic views are less frequently performed, particularly in skeletally immature patients. In Trauma and Orthopedic practice, it is well known that 2 radiographic views are essential for any fracture assessment, with additional views such as oblique views for selected cases. Oblique views are recommended, especially for extremity trauma as this has shown to reduce the incidence of missed diagnoses. Although 2 views of the clavicle, A-P and 45° cephalic tilt are recommended, it is the usual practice in most radiology departments to undertake A-P view of clavicle only. We report a case of a lateral end displaced clavicle fracture in a 16-year-old sustained following football injury. This was completely missed at the initial encounter and the patient later presented with pain and difficulty to move his right shoulder. We believe if this patient had a 45° cephalic tilt view at the time of presentation, the fracture would have been identified and appropriate treatment would have been instituted. Awareness of obtaining a minimum of 2 radiographic views for lateral clavicle fractures will reduce the incidence of missed clavicle fractures.
PubMed: 36425392
DOI: 10.1016/j.radcr.2022.10.041 -
Journal of Human Hypertension Jan 2007To evaluate the persistence of the antihypertensive effect of perindopril 4 mg+indapamide 1.25 mg once daily for up to 72 h using the 'missed-dose' technique.... (Randomized Controlled Trial)
Randomized Controlled Trial
To evaluate the persistence of the antihypertensive effect of perindopril 4 mg+indapamide 1.25 mg once daily for up to 72 h using the 'missed-dose' technique. Hypertensive patients were initially treated with perindopril 2 mg+indapamide 0.625 mg once daily. After 4 weeks, the 135 of 216 patients who still had a diastolic BP> or =85 mm Hg went on to receive perindopril 4 mg+indapamide 1.25 mg daily for a further 8 weeks. During either week 9 or 11, placebo was substituted for perindopril 4 mg+indapamide 1.25 mg on either one or two consecutive days to simulate BP changes, which might occur after one or two missed doses. A 24-h ambulatory BP recording was performed at baseline, after 9 or 11 weeks of perindopril+indapamide therapy and during the simulated missed doses, 24- 48 and 48-72 h after the administration of perindopril 4 mg+indapamide 1.25 mg. Significant (P<0.001) reductions in mean (+/-s.d.) 24-h ambulatory BP (mm Hg) during the first 24 h after perindopril 4 mg+indapamide 1.25 mg therapy versus baseline were noted for patients later randomized to the one missed dose (-15.9+/-10.5/-9.4+/-7.6) or two missed dose (-17.4+/-8.7/-10.3+/-5.1) sub-groups. A significant reduction in BP (P<0.001 versus baseline) was still present on the days when placebo was substituted for perindopril 4 mg+indapamide 1.25 mg with decreases in mean 24-h ambulatory BP from 24 to 48 h and 48 to 72 h after dosing being -11.9+/-10.1/-6.9+/-6.2 and -10.6+/-9.9/-5.8+/-5.7, respectively. Use of the 'missed-dose' technique has demonstrated a prolonged antihypertensive effect for perindopril 4 mg+indapamide 1.25 mg for up to 72 h, supporting the use of this combination as therapy for hypertension.
Topics: Antihypertensive Agents; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Hypertension; Indapamide; Male; Middle Aged; Perindopril; Time Factors
PubMed: 17066085
DOI: 10.1038/sj.jhh.1002107 -
Australasian Physical & Engineering... Mar 2016
Topics: Brachytherapy; Dose-Response Relationship, Radiation; Humans; Neoplasms; Radiographic Image Interpretation, Computer-Assisted; Radiometry; Reproducibility of Results
PubMed: 26964801
DOI: 10.1007/s13246-016-0430-5 -
Pediatric Emergency Care Dec 2021To identify and evaluate dose errors on medication orders that bypassed pharmacist verification in a pediatric emergency department (PED).
OBJECTIVE
To identify and evaluate dose errors on medication orders that bypassed pharmacist verification in a pediatric emergency department (PED).
METHODS
Descriptive, retrospective study about dose errors in an academic PED over 1 year. A report of automatically verified orders (those that bypassed pharmacist verification) was obtained from the electronic medical record. Potential medication dose errors were defined as those greater than 20% above or below standard dose ranges by age or weight. A retrospective chart review was performed for all identified dose errors. For orders deemed erroneous, additional metrics collected included order time of day and day of week and provider training level.
RESULTS
A total of 46,185 medication orders were placed; 32,928 (71%) bypassed pharmacist review. Altogether, 676 orders (2%) were outside standard dose ranges. Ondansetron represented 569 of the 676 orders; most were doses rounded down to 4 mg and technically qualifying as underdoses, but were attributed to practice variance and not further analyzed. The number of orders deemed potentially erroneous was 107: most were wrong dose (75 overdose and 21 underdose), 5 were wrong patient, and 6 were wrong formulation. Ibuprofen, benzodiazepine, and corticosteroid orders had the most errors. No errors resulted in identifiable harm to the patient: 49 were near misses, and 47 reached the patient with no evident harm.
CONCLUSIONS
The overall number of dose errors in autoverified orders was low. Certain medications or ordering modalities may be targeted to enhance patient safety and satisfaction.
Topics: Child; Electronic Health Records; Emergency Service, Hospital; Humans; Medication Errors; Pharmacists; Retrospective Studies
PubMed: 31977774
DOI: 10.1097/PEC.0000000000002024 -
Journal of Gynecology Obstetrics and... Dec 2022To assess the rates of success of the second dose of Misoprostol administration and to evaluate the parameters that affect the success of this approach.
OBJECTIVE
To assess the rates of success of the second dose of Misoprostol administration and to evaluate the parameters that affect the success of this approach.
STUDY DESIGN
This retrospective cohort study was performed using institutional database of Carmel Medical Center between the dates of 1/11/2012-1/11/2017. Patients with ultrasound proven intrauterine abnormal pregnancy, treated for missed abortion or blighted ovum by two doses of intravaginal Misoprostol were included. The primary outcome was the treatment success rate of repeated Misoprostol treatment, and factors affecting this outcome.
RESULTS
Overall, 97 patients were included in the study. The success of repeated dose of Misoprostol was noted in 46 cases (47.4%). A higher success rate was noted in symptomatic women - 64.3% vs. 35.7% in asymptomatic patients (Odds Ratio 2.6, 95% Confidence Interval 1.1-6.5). In addition, marginal significance was noted for pregnancies with an embryonic pulse previously observed (66.7% in the success group vs. 33.3% in failed treatment, p=0.051).
DISCUSSION
Efficacy of a repeated Misoprostol course was shown to have a success rate of 47%%. This success rate is slightly increased in women presenting symptoms of bleeding before first administration. This information is highly important in the clinical discussion with each patient prior choosing a possible treatment.
Topics: Pregnancy; Humans; Female; Misoprostol; Abortion, Missed; Abortifacient Agents, Nonsteroidal; Retrospective Studies; Abortion, Induced
PubMed: 36103968
DOI: 10.1016/j.jogoh.2022.102477 -
Journal of Women's Health (2002) Jan 2023Most women take medication during pregnancy despite limited scientific evidence on safety. We investigated medication use, including changes in and reasons for changes...
Most women take medication during pregnancy despite limited scientific evidence on safety. We investigated medication use, including changes in and reasons for changes in use during pregnancy, with attention to medication use in pregnant women with chronic conditions. We conducted an online survey of pregnant women aged ≥18 years ( = 1,226). We calculated descriptive statistics for aspects of medication use and performed multivariable logistic regression to examine associations between change in use and chronic conditions. Seventy-nine percent of women took at least one medication during pregnancy. Among those, 63.2% made at least one medication change: 42.0% started, 34.9% stopped, 30.0% missed dose(s), and 18.1% lowered dose(s) from that originally prescribed or recommended. More than a third (36.5%) of women who stopped, lowered, or missed medication did so independent of health care provider advice; 54.0% cited concern about birth or developmental defects as reasons for change. Odds of medication change were higher for women with chronic conditions: digestive conditions-starting (adjusted odds ratio [AOR] = 1.8, 95% confidence interval [CI] = 1.1-2.7), stopping (AOR = 2.1, 95% CI = 1.4-3.3), and lowering (AOR = 2.4, 95% CI = 1.7-3.3) medication; mental health conditions-starting (AOR = 1.6, 95% CI = 1.2-2.2), stopping (AOR = 3.0, 95% CI = 2.3-4.0), or missing (AOR = 2.1, 95% CI = 1.6-2.8) medication; pain conditions-stopping (AOR = 2.9, 95% CI = 2.0-4.2); and respiratory conditions-starting (AOR = 2.0, 95% CI = 1.3-3.1), stopping (AOR = 1.7, 95% CI = 1.1-2.6), and missing (AOR = 2.2, 95% CI = 1.4-3.4) medication. Most pregnant women take medication and many, including those with chronic conditions, change their medication use during pregnancy. Medication change may occur independent of health care provider advice and due to women's safety concerns.
Topics: Female; Humans; Pregnancy; Adolescent; Adult; Pregnant Women; Chronic Disease; Surveys and Questionnaires; Mental Disorders
PubMed: 36251939
DOI: 10.1089/jwh.2022.0205 -
Frontline Gastroenterology Apr 2010Colonoscopy is associated with a varying risk of missing colorectal cancer (CRC). The objective of this paper was to review the existing evidence that indicates when... (Review)
Review
Colonoscopy is associated with a varying risk of missing colorectal cancer (CRC). The objective of this paper was to review the existing evidence that indicates when colonoscopy may miss cancer in usual clinical practice and to provide information that would be helpful to endoscopists in their daily practice. CRC is diagnosed within 3 years in about 5% of persons with CRC who undergo colonoscopy in whom the cancer is not detected. Future research should be directed at disentangling the relative contributions of tumour biology and colonoscopy quality in explaining this result. When consent is obtained for colonoscopy, patients must be informed of the small risk that a cancer may not be detected. Steps that can be taken to address colonoscopy quality include formal training in colonoscopy and polypectomy technique, coupled with maintenance of skills by performing at least 300 colonoscopies per year. The use of split dose bowel preparation is advised. Colonoscopy should be completed to the caecum with documentation of landmarks (ileocaecal valve; appendiceal orifice). Careful colonoscopy technique includes examining the proximal sides of flexures and folds, washing and suctioning debris and ensuring adequate colonic distension. Caecal intubation and adenoma detection rates should be reported and reviewed. Lesions should be completely removed at polypectomy and attention given to appropriate surveillance.
PubMed: 28839544
DOI: 10.1136/fg.2009.000257 -
AJNR. American Journal of Neuroradiology Jun 2016The American College of Radiology-American Society of Neuroradiology-Society for Pediatric Radiology Practice Parameter for a neck CT suggests that coverage should be...
BACKGROUND AND PURPOSE
The American College of Radiology-American Society of Neuroradiology-Society for Pediatric Radiology Practice Parameter for a neck CT suggests that coverage should be from the sella to the aortic arch. It also recommends using CT scans judiciously to achieve the clinical objective. Our purpose was to analyze the potential dose reduction by decreasing the scan length of a neck CT and to assess for any clinically relevant information that might be missed from this modified approach.
MATERIALS AND METHODS
This retrospective study included 126 children who underwent a neck CT between August 1, 2013, and September 30, 2014. Alteration of the scan length for the modified CT was suggested on the topographic image on the basis of the indication of the study, with the reader blinded to the images and the report. The CT dose index volume of the original scan was multiplied by the new scan length to calculate the dose-length product of the modified study. The effective dose was calculated for the original and modified studies by using age-based conversion factors from the American Association of Physicists in Medicine Report No. 96.
RESULTS
Decreasing the scan length resulted in an average estimated dose reduction of 47%. The average reduction in scan length was 10.4 cm, decreasing the overall coverage by 48%. The change in scan length did not result in any missed findings that altered management. Of the 27 abscesses in this study, none extended to the mediastinum. All of the lesions in question were completely covered.
CONCLUSIONS
Decreasing the scan length of a neck CT according to the indication provides a significant savings in radiation dose, while not altering diagnostic ability or management.
Topics: Child; Humans; Neck; Radiation Dosage; Radiology; Retrospective Studies; Tomography, X-Ray Computed; United States
PubMed: 26869466
DOI: 10.3174/ajnr.A4672 -
European Journal of Orthopaedic Surgery... May 2021The utilization of aspirin for VTE prophylaxis following TJA has increased due to updated clinical practice guidelines. Aspirin is the only approved VTE prophylaxis...
INTRODUCTION
The utilization of aspirin for VTE prophylaxis following TJA has increased due to updated clinical practice guidelines. Aspirin is the only approved VTE prophylaxis medication that does not require a prescription, but adherence and tolerance remain unknown. We hypothesized decreased patient compliance utilizing full-strength 325 mg aspirin twice daily following TJA when compared to low-dose 81 mg twice daily. We also investigated the reasons why patients may elect to stop the medication earlier than 28 days.
METHODS
A consecutive series of patients undergoing primary total hip or knee arthroplasty utilizing 325 or 81 mg of EC aspirin twice daily for 4 weeks were surveyed to determine compliance with use and any adverse events related to the medication. Fisher's exact test was used to determine statistical significance.
RESULTS
404 patients were enrolled with 199 patients prescribed the 325 mg regimen. Fifty-two patients who were prescribed 325 mg missed a dose versus 51 patients who were prescribed 81 mg (p = 0.082). No significant difference in the frequency of missed doses (missing < 5 doses, 5-10 doses, > 10 doses) between the treatment regimens (p = 0.78, 0.39 and 0.83, respectively). Most commonly cited reason for stopping aspirin in both treatment groups was gastrointestinal issues (10.5% and 7%, respectively).
DISCUSSION AND CONCLUSIONS
By surveying patients on their use of aspirin we find no difference in adherence between full-strength and low-dose treatment regimens. Additionally, we have a better understanding of the reasons for noncompliance as GI upset was a relatively common complaint with both doses.
Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Humans; Patient Compliance; Venous Thromboembolism
PubMed: 33211234
DOI: 10.1007/s00590-020-02833-w