Age at Onset of Spinal Cord Injury is Associated with Increased Inpatient Care Needs, Reduced Independence at Discharge and a Higher Risk of Institutionalization after Primary Inpatient Rehabilitation.

OBJECTIVE: To investigate the influence of age at onset of spinal cord injury on length of stay, inpatient therapy and nursing hours, independence at discharge and risk of institutionalization. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 250 patients with a newly acquired traumatic or non-traumatic spinal cord injury undergoing primary inpatient rehabilitation in a Swiss spinal cord injury specialized clinic between 2017 and 2019. METHODS: Multiple regression analysis was used to determine if age, in addition to clinical characteristics (co-morbidities, secondary complications and spinal cord injury severity), affects inpatient rehabilitation parameters (length of stay, daily nursing hours and daily therapy hours), independence at discharge (Spinal Cord Independence Measure III) and place of discharge (private residence vs institution). RESULTS: Chronological age correlated with the number of co-morbidities and secondary complications. Older age was associated with increased daily nursing care and reduced independence at discharge. However, both were also influenced by co-morbidities, secondary complications and severity of spinal cord injury. Length of stay and daily therapy hours were age-independent. Odds for institutionalization after discharge increased significantly, by 1.03-fold per year of age. CONCLUSION: Age at onset of spinal cord injury predicted inpatient nursing care, independence at discharge and the risk of institutionalization after primary inpatient rehabilitation. Co-morbidities, secondary complications and severity of spinal cord injury were also important influencing factors.

Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis.

OBJECTIVES: Our goal was to evaluate the impact of the discontinuation times of dual antiplatelet therapy with clopidogrel, prasugrel or ticagrelor on postoperative bleeding rates and the use of blood products in patients undergoing isolated urgent coronary artery bypass grafting (CABG). METHODS: We retrospectively analysed 334 patients with acute coronary syndrome undergoing urgent CABG at the University Hospital Basel. A total of 262 patients continued to take dual antiplatelet therapy during the surgery (72 received clopidogrel; 68, prasugrel; and 122, ticagrelor). They were stratified by the discontinuation time of dual antiplatelet therapy (<24 h, 24-48 h, 48-72 h and >72 h). Seventy-two patients taking acetylsalicylic acid (ASA) as monotherapy served as a comparison group. RESULTS: Median postsurgical bleeding rates were significantly higher with ticagrelor if it was discontinued <24 h [1220 ml, interquartile range (IQR) 978-1520 ml; P < 0.001], 24-48 h (1200 ml, IQR 800-1550 ml; P < 0.001) and 48-72 h (1100 ml, IQR 845-1245 ml; P = 0.036) but not if discontinued >72 h (700 ml, IQR 520-825 ml; P = 0.22) and with prasugrel if discontinued <24 h (1320 ml, IQR 900-1950 ml; P < 0.001) but not if discontinued 24-48 h (1050 ml, IQR 638-1438 ml; P = 0.089) or >72 h (750 ml, IQR 488-1040; P = 0.63) compared to ASA monotherapy (800 ml, IQR 593-1043 ml). The postsurgical use of blood products compared to ASA monotherapy (0, IQR 0-2 units) was significantly higher with ticagrelor and prasugrel if discontinued <24 h (2.5 units, IQR 0-6; P < 0.001 and 2 units, IQR 1-6; P < 0.001, respectively). CONCLUSIONS: Discontinuation of ticagrelor and prasugrel for more than 72 h before urgent CABG was not associated with higher bleeding rates compared to treatment with ASA monotherapy. In contrast, discontinuation for less than 24 h was associated with higher use of blood products. For ticagrelor, this study supports evidence and recent guidelines proposing a shorter discontinuation time of 3 days and raises the question of whether the same could be true for prasugrel.

Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU.

BACKGROUND: Prophylaxis for gastrointestinal stress ulceration is frequently given to patients in the intensive care unit (ICU), but its risks and benefits are unclear. METHODS: In this European, multicenter, parallel-group, blinded trial, we randomly assigned adults who had been admitted to the ICU for an acute condition (i.e., an unplanned admission) and who were at risk for gastrointestinal bleeding to receive 40 mg of intravenous pantoprazole (a proton-pump inhibitor) or placebo daily during the ICU stay. The primary outcome was death by 90 days after randomization. RESULTS: A total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group. Data on the primary outcome were available for 3282 patients (99.5%). At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died (relative risk, 1.02; 95% confidence interval [CI], 0.91 to 1.13; P=0.76). During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups. CONCLUSIONS: Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo. (Funded by Innovation Fund Denmark and others; SUP-ICU ClinicalTrials.gov number, NCT02467621 .).