Risk of hemorrhage in patients with chronic liver disease and coagulopathy receiving pharmacologic venous thromboembolism prophylaxis.

STUDY OBJECTIVE: To evaluate the impact of pharmacologic venous thromboembolism (VTE) prophylaxis on risk of hemorrhage while hospitalized in patients with chronic liver disease (CLD) and concurrent coagulopathy. DESIGN: Retrospective, multicenter chart review. SETTING: Five hospital, university-affiliated network in eastern Pennsylvania. PATIENTS: Patients admitted to the network from January 1, 2012, until December 31, 2012, with ICD-9 code consistent with CLD and elevated international normalized ratio of 1.5 or greater not secondary to anticoagulation. MEASUREMENTS AND MAIN RESULTS: Two hundred fifty-six patients met criteria for analysis, with 80 having received pharmacologic VTE prophylaxis and 176 having received no pharmacologic VTE prophylaxis. Differences were observed in the primary outcome of overall hemorrhage (composite of major and minor hemorrhage) for patients receiving VTE prophylaxis versus no VTE prophylaxis (17.5% vs 7.4%, p=0.02). Logistic regression revealed covariates independently associated with increased hemorrhage risk were pharmacologic VTE prophylaxis use (adjusted odds ratio [AOR] 3.64, p=0.004), increasing international normalized ratio (AOR 1.31, p=0.007), and decreasing platelet count (AOR 0.99, p=0.03). CONCLUSIONS: Patients with CLD and concurrent coagulopathy receiving pharmacologic VTE prophylaxis are at an increased risk of overall hemorrhage. Clinical implications remain unclear secondary to the difference in rate of overall hemorrhage being driven primarily by a difference in minor hemorrhage. In addition, no difference was demonstrated in many assessed clinically relevant markers.

Risk factors for mesh extrusion after prolapse surgery: a case-control study.

OBJECTIVES: To identify risk factors for mesh extrusion in women undergoing pelvic organ prolapse repair by abdominal sacral colpopexy (ASC) or vaginal mesh procedure (VMP). METHODS: A multicenter case-control study of patients who underwent ASC or VMP from 2006 to 2009 identified using diagnosis and procedure coding. Cases were defined as women who underwent eligible index procedure with synthetic mesh and had mesh visible through the vaginal epithelium at postoperative evaluation; controls were matched in an approximate 1:3 ratio by date and type of procedure. Two conditional logistic regression models were constructed to assess variables associated with mesh extrusion among women who underwent ASC and among women who underwent VMP. RESULTS: Eighty-four cases were identified (43 cases after ASC and 41 cases after VMP), and 252 patients were matched as controls (147 patients who underwent ASC and 105 patients who underwent VMP). Concomitant hysterectomy was positively associated with mesh extrusion) among women who underwent ASC (adjusted odds ratio, 3.18; 95% confidence interval, 1.27-7.93; P = 0.01) and VMP (adjusted odds ratio, 3.72, 95% confidence interval, 1.20-11.54; P = 0.02). Age, race, type of vaginal incision, menopausal status, medical comorbidities, and smoking were not significantly associated with extrusion in either group. CONCLUSIONS: Concomitant hysterectomy is a risk factor for mesh extrusion after ASC and VMPs. This information may be helpful during informed preoperative counseling and planning.

Do emergency physicians admit more or fewer patients on busy days?

BACKGROUND: Although the issues concerning the impact of emergency department (ED) overcrowding have been the subject of much recent concern, there are few data regarding the effect of ED census on emergency physician behavior with respect to the decision to admit patients. Admission rates might either increase or decrease on busy days, when the system and the physician are under stress. STUDY OBJECTIVE: The purpose of this study was to determine if ED physicians change their admitting behavior depending on ED census. METHODS: This was a retrospective review of 3 months' data (92 consecutive days, July 9-October 9, 2006) in a community ED with an annual census of approximately 70,000 patients and an emergency medicine residency program. We defined each of the 92 days to be either "busy" (> 180 patients seen), "slow" (< 147 patients seen) or "medium" (147-180 patients seen). We then compared the rates of admission to the hospital on the "busy," "medium," and "slow" days. We also compared each attending physician's personal rates of admission on slow days to his or her rate of admission on medium or busy days. ED staffing was constant throughout the study period. All comparisons were with chi-squared. RESULTS: There were 14,969 patients seen in the ED during the 92 study days. On "busy" days, 20.1% of the 3400 patients were admitted to the hospital; on "medium" days, 20.6% of the 9057 patients were admitted; on "slow" days, 19.7% of the 2512 patients were admitted. There was no significant association between the level of patient volume in the ED and rate of admission (p = 0.55). When comparing each of 14 attending physicians to him- or herself, there was no significant association found between rate of admission and ED census (all p values > 0.3). All three categories of days, "busy," "medium," and "slow" did not differ in terms of acuity as judged by triage level distribution. CONCLUSION: The likelihood of a patient's admission vs. discharge is not affected by ED patient volume. Furthermore, we found no evidence that an individual physician's admitting behavior was associated with ED patient volume.