Is tramadol associated to bleeding peptic ulcer? A nationwide case-control study in hospitalized Swedish patients.

AIMS: Tramadol, a widely used analgesic drug, inhibits the reuptake of noradrenaline and serotonin impairing the aggregation function of thrombocytes. However, the risk for severe bleeding has previously not been studied. The aim of the present study is to investigate the association between tramadol and bleeding peptic ulcer in the Swedish population. METHODS: In this register based case-control study based on the Swedish national patient registry and prescription drug registry, we included 18 306 patients hospitalized with a first-time diagnosis of bleeding peptic ulcer. For every case, 4 matched controls were included. To investigate the temporal aspects of tramadol induced bleeding ulcer, exposure was divided into patients with newly initiated and ongoing treatment. To explore a possible confounding by indication, the effect of codeine, a drug also prescribed for the treatment of moderate pain, but not known to affect thrombocyte function, was investigated. Univariable and multivariable logistic regression was used to analyse the association between tramadol use and bleeding ulcer. RESULTS: Tramadol was associated with an increased risk of bleeding ulcer (adjusted odds ratio (aOR) 2.1, 95% confidence interval: (2.0-2.3). The association was stronger for newly initiated treatment with tramadol 2.8 (2.5-3.2) and weaker for ongoing treatment 1.7 (1.6-1.9). Codeine was also associated with an increased risk of bleeding ulcer 1.9 (1.7-2.1) and this association was also stronger for newly initiated treatment with codeine 2.3 (2.0-2.6) and weaker for ongoing treatment 1.7 (1.5-1.9). CONCLUSION: Treatment with tramadol was associated with an increased risk of bleeding peptic ulcer. Most of this association may be mediated by factors related to the pain condition rather than the pharmacologic effect per se.

Can early follow-up after deliberate self-harm reduce repetition? A prospective study of 325 patients.

BACKGROUND: Patients who deliberately harm themselves often repeat their self-destructive acts. The objective of this study was to assess whether a follow-up visit within 10 days to a psychiatric consultant could reduce the frequency of repeated deliberate self-harm (DSH). METHODS: A cohort of 325 consecutive DSH patients attending two large emergency departments in Stockholm, Sweden, were included and followed for 6 months. Any visit to a psychiatric consultant within 10 days was registered as an early follow-up. Repeated DSH episode within 6 months among the 325 patients was detected via nationwide registers. MAIN OUTCOME MEASURE: Repeated DSH within 6 months. RESULTS: At 6 months follow-up 22 (24%) of 92 patients with an early follow-up had repeated their DSH acts compared to 58 (25%) of 233 patients without an early follow-up (OR 1.06 (95% CI: 0.60-1.85) p-value 0.85). After adjustment for possible confounders, multivariable analysis showed an OR of 1.22 (95% CI: 0.62-2.38, p-value 0.56). LIMITATIONS: Early follow-up was registered as any visit to a psychiatric consultant and no information regarding actions taken at the visit were obtained. CONCLUSION: After adjusting for other factors associated with repetition there was an association of patients who were offered and thereafter attended an early follow-up visit and a decreased risk of repeated DSH.

Can repetition of deliberate self-harm be predicted? A prospective multicenter study validating clinical decision rules.

BACKGROUND: Clinical decision rules have been developed to help identify patients at high risk of repeating deliberate self-harm actions. The objective of this study was to prospectively validate the clinical decision rules', Södersjukhuset Self-Harm Rule and Manchester Self-Harm Rule, ability to predict repetition of deliberate self-harm (DSH). METHODS: A consecutive series of 325 patients attending two large emergency departments in Stockholm, Sweden due to DSH were included and followed for six months. Predictive factors were collected from hospital charts at the emergency department. A nationwide register-based follow-up of new DSH within six months was used. We calculated the sensitivity and specificity to evaluate the different decision rules' ability to identify repetition of DSH. Main outcome measure repeated DSH within six months. RESULTS: The cumulative incidence for patients repeating within six months was 24.6% (95% CI: 19.9-29.3). Application of Södersjukhuset Self-Harm Rule yielded a sensitivity of 89% (95%CI: 79.2-94.4) and a specificity of 11% (95%CI: 7.9-16.2). Application of Manchester Self-Harm Rule to our material yielded a sensitivity of 94% (95%CI: 85.4-97.7) and a specificity of 18% (95%CI: 13.8-23.9). LIMITATIONS: If data regarding predictive factors were missing it was not possible to investigate this further and in the statistical analysis missing data was classified as no. This would imply that the predicted risks may be underestimated. CONCLUSION: Clinical decision rules could be used as a compliment providing important additional information regarding risk of repetition in an ED setting when focusing on high sensitivity.

Deliberate self-harm patients in the emergency department: who will repeat and who will not? Validation and development of clinical decision rules.

OBJECTIVES: (1) Validate an existing clinical tool for assessing risk after deliberate self-harm (DSH), Manchester Self-Harm Rule, in a new setting and new population, (2) develop a clinical decision rule based on factors associated with repeated self-harm in a Swedish population and (3) compare these rules. DESIGN: A consecutive series of 1524 patients attending one of Scandinavia's largest emergency departments (ED) due to DSH during a 3-year period were included. Explanatory factors were collected from hospital charts and national databases. A nationwide register-based follow-up of new DSH episode or death by suicide within 6 months was used. We used logistic regression, area under the curve and classification trees to identify factors associated with repetition. To evaluate the ability of different decision rules to identify patients who will repeat DSH, we calculated the sensitivity and specificity. MAIN OUTCOME MEASURE: Repeated DSH or suicide within 6 months. RESULTS: The cumulative incidence for patients repeating within 6 months was 20.3% (95% CI 18.0% to 22.0%). Application of Manchester Self-Harm Rule to our material yielded a sensitivity of 89% and a specificity of 21%. The clinical decision rule based on four factors associated with repetition in the Swedish population yielded a sensitivity of 90% and a specificity of 18%. CONCLUSIONS: Application of either rules, with high sensitivity, may facilitate assessment in the ED and help focus right resources on patients at a higher risk. Irrespective of the choice of decision rule, it is difficult to separate those who will repeat from those who will not due to low specificity.

Deliberate self-harm patients in the emergency department: factors associated with repeated self-harm among 1524 patients.

OBJECTIVES: (1) investigate risk factors associated with repeated deliberate self-harm (DSH) among patients attending the emergency department due to DSH, (2) stratify these patients into risk categories for repeated DSH and (3) estimate the proportion of repeated DSH within 12 months. DESIGN: A consecutive series of individuals who attended one of Scandinavia's largest emergency departments during 2003-2005 due to DSH. Data on sociodemographic factors, diagnoses and treatment, previous DSH at any healthcare facility in Sweden (2002-2005) and circumstances of the index DSH episode were collected from hospital charts and national databases. A nationwide register based on follow-ups of any new DSH or death by suicide during 2003-2006. MAIN OUTCOME MEASURE: Repeated DSH episode or suicide. RESULTS: 1524 patients were included. The cumulative incidence for patients repeating DSH within 12 months after the index episode was 26.8% (95% CI: 24.6 to 29.0). Risk factors associated with repeating DSH included previous DSH, female gender, self-injury as a method for DSH and if the self-injury required a surgical procedure, current psychiatric or antidepressant treatment and if the patient suffered from a substance use disorder or adult personality disorder or did not have children under the age of six. CONCLUSION: Patients attending an emergency department due to DSH have a high risk of repeating their self-harm behaviour. We present a model for risk stratification for repeated DSH describing low-risk (18%), median-risk (28% to 32%) and high-risk (47% to 72%). Our results might help caretakers to direct optimal resources to these groups.

The impact of trauma mechanism on outcome: a follow-up study on health-related quality of life after major trauma.

OBJECTIVES: To relate the trauma mechanism in a trauma population to health-related quality of life outcomes and mortality rates. METHODS: A consecutive series of patients (>15 years old) with major injuries [Injury Severity Score (ISS) ≥10] treated during a 2-year period at a general hospital in a city area were included (n = 458). Baseline data were collected from medical records, and patients were followed up 12 months post injury. Outcome was measured by health-related quality of life (HRQoL) according to the SF-36 and musculoskeletal function according to the short musculoskeletal function assessment (SMFA). Mortality rates were collected during 7 years. RESULTS: Of all patients, 86.9% had an unintentional injury, 4.4% had a self-inflicted injury, and 8.7% had been assaulted. The mortality rate during the acute phase and at 7 years post trauma did not differ between the groups with different trauma mechanisms. At 12 months, patients with unintentional injuries and assault victims had SF-36 ratings comparable to the general population, while patients with self-inflicted injuries had worse ratings in all SF-36 domains except physical function and general health. There were no differences between the groups regarding SMFA results. CONCLUSION: Even though the follow-up rate was only 53%, this study showed that, at 12 months, patients with self-inflicted injuries had significantly lower HRQoL ratings. There was no difference in mortality with regard to trauma mechanism. Cooperation between emergency service and psychiatric care early in the acute phase could provide a golden opportunity to reach this patient group.