The study examined the association between proton pump inhibitor (PPI) prescriptions and the risk of community acquired pneumonia using data from the UK's Clinical Practice Research Datalink. Three methods were used: a cohort study comparing PPI users to non-users adjusted for confounders, a self-controlled case series comparing periods before and after PPI use, and examining event rates before and after the first PPI prescription. All methods suggested the observed association between PPI use and pneumonia was likely due entirely to underlying confounding factors present before PPI use, rather than being caused by PPI use itself.
Efficacy of Xuebijing injection for the treatment of coronavirus disease 2019...LucyPi1
Abstract Background: To evaluate the mechanism of Chinese patent drug Xuebijing (XBJ) injection in the treatment of a new coronavirus disease 2019 (COVID-19) based on network pharmacology and molecular docking technology. Methods: The TCMSP database was employed to collect and screen the active ingredients of the Chinese herb contained in the XBJ injection. The GeneCards database and STRING database were applied to collect and expand the targets of COVID-19 and compare and screen the related targets of COVID-19 by XBJ injection. Cytoscape was employed to build a network connecting Chinese medicine, compounds, targets, disease, and topology analysis was performed via the Network Analyzer to screen the key ingredients and targets. The software of Schrödinger molecular docking was used to verify the binding activity of the key ingredients of XBJ injection and the key targets of COVID-19. Metascape platform and DAVID database were utilized to conduct Gene Ontology analysis and Kyoto Encyclopedia of Genes and Genomes analysis on the key targets of COVID-19 treated by XBJ injection. Results: Eight key compounds and 15 key targets were screened and verified by molecular docking; these key compounds included luteolin, quercetin, baicalein, and kaempferol. The key targets included DPP4, AR, ESR1, CALM1, and protein kinase 1. Gene Ontology analysis involved an apoptosis and hypoxia reaction and the changes in blood vessel morphology. Kyoto Encyclopedia of Genes and Genomes analysis involved signaling pathways of hypoxia inducible factor-1, VEGF, and PI3K/AKT/NF-κB. Conclusion: The mechanism of XBJ injection when used to treat COVID-19 should be further investigated as the key compounds in XBJ regulated the expression of key targets such as protein kinase 1, VEGF-A, B-cell lymphoma-2, and TNF, which affected the COVID-19 receptors such as angiotensin-converting enzyme 2 and signaling pathways like hypoxia inducible factor-1, PI3K-Akt, and NF-κB, which alleviated the inflammation, respiratory distress, and hypoxia caused by COVID-19 infection.
Efficacy of Xuebijing injection for the treatment of coronavirus disease 2019...LucyPi1
Abstract Background: To evaluate the mechanism of Chinese patent drug Xuebijing (XBJ) injection in the treatment of a new coronavirus disease 2019 (COVID-19) based on network pharmacology and molecular docking technology. Methods: The TCMSP database was employed to collect and screen the active ingredients of the Chinese herb contained in the XBJ injection. The GeneCards database and STRING database were applied to collect and expand the targets of COVID-19 and compare and screen the related targets of COVID-19 by XBJ injection. Cytoscape was employed to build a network connecting Chinese medicine, compounds, targets, disease, and topology analysis was performed via the Network Analyzer to screen the key ingredients and targets. The software of Schrödinger molecular docking was used to verify the binding activity of the key ingredients of XBJ injection and the key targets of COVID-19. Metascape platform and DAVID database were utilized to conduct Gene Ontology analysis and Kyoto Encyclopedia of Genes and Genomes analysis on the key targets of COVID-19 treated by XBJ injection. Results: Eight key compounds and 15 key targets were screened and verified by molecular docking; these key compounds included luteolin, quercetin, baicalein, and kaempferol. The key targets included DPP4, AR, ESR1, CALM1, and protein kinase 1. Gene Ontology analysis involved an apoptosis and hypoxia reaction and the changes in blood vessel morphology. Kyoto Encyclopedia of Genes and Genomes analysis involved signaling pathways of hypoxia inducible factor-1, VEGF, and PI3K/AKT/NF-κB. Conclusion: The mechanism of XBJ injection when used to treat COVID-19 should be further investigated as the key compounds in XBJ regulated the expression of key targets such as protein kinase 1, VEGF-A, B-cell lymphoma-2, and TNF, which affected the COVID-19 receptors such as angiotensin-converting enzyme 2 and signaling pathways like hypoxia inducible factor-1, PI3K-Akt, and NF-κB, which alleviated the inflammation, respiratory distress, and hypoxia caused by COVID-19 infection.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
A Study to Assess the Effectiveness of Planned Teaching Program on the Knowle...ijtsrd
Malnutrition and Tuberculosis chronic infectious disease are both problems of considerable magnitude in the most underdeveloped regions of the world. Malnutrition can leads to secondary immunodeficiency that increase the host susceptibility to infection. The aim of the study was to assess the effectiveness of planned teaching program on the knowledge and practice regarding dietary pattern among mothers of children with tuberculosis admitted in pediatric ward. Quasi experimental with two groups pre test post test design was used for 60 mothers at IPD and OPD of pediatric department and purposive sampling technique was used. Self structured questionnaire was used to assess knowledge and checklist for practice. In post test experimental group mothers have 63.3 average knowledge, 26.6 poor knowledge and 10 good knowledge while in the control group, 53.3 poor knowledge, 46.6 average knowledge and non hove good knowledge. In experimental group mean score was 17.9 1.96 while in control group mean score was 11.8 2.99. At the “p” value 0.05, the calculated t value 3.21 was compared with the tabulated value 2.01 . In post test experimental group, mothers have 53.3 good practice, 46.6 average practice and none have poor practice while in the control group, 63.33 average practice, 23.3 poor practice and 13.3 good practice. In experimental group mean score was 19.13 1.99 while in the control group, mean score was 14.06 2.85.At the “p” value 0.05, the calculated t value 3.28 was compared with the tabulated value 2.01 . These finding reveals that the planned teaching program on dietary pattern was effective. Mrs. Anchal Tiwari | Mrs. Anugrah Charan | Dr. Sarika Gupta "A Study to Assess the Effectiveness of Planned Teaching Program on the Knowledge and Practice Regarding Dietary Pattern among Mothers of Children with Tuberculosis Admitted in Pediatric Ward at KGMU Hospital, Lucknowv" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-2 , February 2021, URL: https://www.ijtsrd.com/papers/ijtsrd38591.pdf Paper Url: https://www.ijtsrd.com/medicine/nursing/38591/a-study-to-assess-the-effectiveness-of-planned-teaching-program-on-the-knowledge-and-practice-regarding-dietary-pattern-among-mothers-of-children-with-tuberculosis-admitted-in-pediatric-ward-at-kgmu-hospital-lucknowv/mrs-anchal-tiwari
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
NCCR 2020: Conference Of Very Important Disease (COVID-19) | 24 - 26 August 2020
Young Investigator Awards Presentation
Authors: Kuan Pei Xuan1,2, Kuldip Kaur Prem Singh3, Law Kian Boon1, Mohd Aizuddin Abdul Rahman1,2, Mohan Dass Pathmanathan1,2, Wong Xin Ci1, Kalaiarasu M. Peariasamy1,2, Goh Pik Pin1
1 Digital Health Research and Innovation, Institute for Clinical Research, Malaysia
2 Clinical Research Centre, Hospital Sungai Buloh, Malaysia
3 Director Office, Hospital Sungai Buloh, Malaysia
https://doi.org/10.5281/zenodo.4004360
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Etiologia de la celulitis y Predicción clínica de la enfermedad Estreptocócic...Alex Castañeda-Sabogal
Etiologia de la celulitis. Estudio prospectivo y predicción clínica de la infeccion por Estreptococcus basado en la frecuencia encontrada de las especies de estreptococo
A Study to Assess the Effectiveness of Planned Teaching Program on the Knowle...ijtsrd
Malnutrition and Tuberculosis chronic infectious disease are both problems of considerable magnitude in the most underdeveloped regions of the world. Malnutrition can leads to secondary immunodeficiency that increase the host susceptibility to infection. The aim of the study was to assess the effectiveness of planned teaching program on the knowledge and practice regarding dietary pattern among mothers of children with tuberculosis admitted in pediatric ward. Quasi experimental with two groups pre test post test design was used for 60 mothers at IPD and OPD of pediatric department and purposive sampling technique was used. Self structured questionnaire was used to assess knowledge and checklist for practice. In post test experimental group mothers have 63.3 average knowledge, 26.6 poor knowledge and 10 good knowledge while in the control group, 53.3 poor knowledge, 46.6 average knowledge and non hove good knowledge. In experimental group mean score was 17.9 1.96 while in control group mean score was 11.8 2.99. At the “p” value 0.05, the calculated t value 3.21 was compared with the tabulated value 2.01 . In post test experimental group, mothers have 53.3 good practice, 46.6 average practice and none have poor practice while in the control group, 63.33 average practice, 23.3 poor practice and 13.3 good practice. In experimental group mean score was 19.13 1.99 while in the control group, mean score was 14.06 2.85.At the “p” value 0.05, the calculated t value 3.28 was compared with the tabulated value 2.01 . These finding reveals that the planned teaching program on dietary pattern was effective. Mrs. Anchal Tiwari | Mrs. Anugrah Charan | Dr. Sarika Gupta "A Study to Assess the Effectiveness of Planned Teaching Program on the Knowledge and Practice Regarding Dietary Pattern among Mothers of Children with Tuberculosis Admitted in Pediatric Ward at KGMU Hospital, Lucknowv" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-2 , February 2021, URL: https://www.ijtsrd.com/papers/ijtsrd38591.pdf Paper Url: https://www.ijtsrd.com/medicine/nursing/38591/a-study-to-assess-the-effectiveness-of-planned-teaching-program-on-the-knowledge-and-practice-regarding-dietary-pattern-among-mothers-of-children-with-tuberculosis-admitted-in-pediatric-ward-at-kgmu-hospital-lucknowv/mrs-anchal-tiwari
Observational Study on 255 Mechanically Ventilated Covid Patients at the Beginning of the USA Pandemic
This article is a preprint and has not been peer-reviewed.
Twitter: @MattisVollan
NCCR 2020: Conference Of Very Important Disease (COVID-19) | 24 - 26 August 2020
Young Investigator Awards Presentation
Authors: Kuan Pei Xuan1,2, Kuldip Kaur Prem Singh3, Law Kian Boon1, Mohd Aizuddin Abdul Rahman1,2, Mohan Dass Pathmanathan1,2, Wong Xin Ci1, Kalaiarasu M. Peariasamy1,2, Goh Pik Pin1
1 Digital Health Research and Innovation, Institute for Clinical Research, Malaysia
2 Clinical Research Centre, Hospital Sungai Buloh, Malaysia
3 Director Office, Hospital Sungai Buloh, Malaysia
https://doi.org/10.5281/zenodo.4004360
Implementation and evaluation of anursing assessmentstandin.docxwilcockiris
Implementation and evaluation of a
nursing assessment/standing orders–
based inpatient pneumococcal
vaccination program
Carl Eckrode, MPH, RRT-NPS,b Nancy Church, RN, MT,a and Woodruff J. English III, MDa
Portland and Gresham, Oregon
Background: Pneumococcal vaccination is recommended for patients aged 65 years and greater; inpatient vaccination has been
suggested as means to increase vaccination rates is this population. Our hospital implemented an inpatient pneumococcal vacci-
nation program, and expanded the population of interest to include patients aged 2 to 64 years with risk factors for pneumococcal
bacteremia. We studied the outcomes of this program to determine if the rate of pneumococcal vaccination opportunities and
pneumococcal vaccination rate could be significantly increased through the application of an in-hospital pneumococcal vaccina-
tion program, based on standing orders and assessment by Registered Nurses, when compared to our previous method of physi-
cian assessment and written vaccination order for each patient.
Methods: Subjects were inpatients admitted to non-intensive care units of our hospital from August to December of 2004. Cases
were aged greater than 65 years, or were greater than 2 years of age with selected risk factors. Patients with previous pneumococcal
vaccination with the past five years, in terminal or comfort care, those allergic to vaccine components, patients who received organ
or bone marrow transplants in the year prior to the study, and those physicians barred them from the vaccination protocol were
excluded. Program effectiveness was evaluated through retrospective evaluation of medical records to determine if subjects had
been evaluated for vaccination eligibility, and if subjects were eligible, whether or not they had received pneumococcal vaccination.
Results: Overall vaccination opportunity rate after implementation of the standing orders-based program increased form 8.6% to
59.1%, and overall vaccination rates improved form 0% to 15.4%. The study found a statistically significant difference in the rate
of pneumococcal vaccination opportunities (x2 = 182.46, p = .00) and the pneumococcal vaccination rate (x2 = 56, p = .00)
between the two methods of assessment and vaccination; these results are attributable to the study intervention.
Conclusions: The study program contributed to increased overall vaccination opportunity and vaccination rates, when compared
to the previous method. The overall rates of vaccination attained by this program were often lower than those reported in the ex-
isting literature for other program designs; however, this may be due to an unusually high rate of vaccination refusal. (Am J Infect
Control 2007;35:508-15.)
The significance of invasive pneumococcal disease
cannot be understated, because disease caused by
Streptococcus pneumoniae has been reported to be
responsible for an estimated 36% of community-
acquired pneumonia, an estimated 50% of nosocomial
pneumonias,.
PEPTIC (Holden Young - Roseman University College of Pharmacy)HoldenYoung3
PEPTIC (Holden Young - Roseman University College of Pharmacy)
Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine-2 receptor blockers on in-hospital
mortality among ICU patients receiving invasive mechanical ventilation (PEPTIC).
JAMA . 2020; 323(7):616-626
Hospital treated pneumonia - Diagnosis and TreatmentBostonsp
In 2014, US healthcare spending exceeded $3.0 trillion with nearly 1/3 spent on hospitalizations. Informed by real-world data from an Electronic Health Record (EHR) database of clinical and administrative records spanning 273 million encounters for 60 million patients in 600+ hospitals across the US, Boston Strategic Partners (BSP) Clinical Insights report, Hospital-Treated Pneumonia, estimates 30% of all hospital discharges involve treatment of infectious organisms. Pneumonia is responsible for an estimated 12% of all hospital stays. At an average cost of $15,500 per occurrence, we estimate that hospitalizations for severe infections account for around $212 billion in annual spending or 7% of total healthcare expenditure. In this report, we conduct an in-depth analysis of pneumonia patient characteristics, medication management, costs, and laboratory testing.
Hospital-Treated Pneumonia is available at www.bostonsp.com/reports.
Gram-negative bacteria are the likely causative agents of most pneumonia infections and physicians treat most of these patients with levofloxacin, ceftriaxone, and azithromycin. From 2010-2015, drug resistant organisms caused a surprising 20% of bacterial pneumonia infections.
This report provides quantitative, objective data captured by hospitals contributing to Cerner Health Facts. This data provides real-world patient encounters and reflects real physician decisions and encounter characteristics (e.g. patient response to therapy and outcomes) in key areas, such as antibiotic resistant pathogens and antimicrobial stewardship.
Central Line-associated Bloodstream Infections.Walden UniversiMaximaSheffield592
Central Line-associated Bloodstream Infections.
Walden University
Dr. Linda Johanson
Francis Mercado
1
Identification and description of the clinical issue.
The clinical issue or problem identified for my study is the central line bloodstream infections (CLABSI)
Central line bloodstream infections(CLABSI) is a health condition that affects many people.
It occurs when pathogens such as bacteria and other germs invade the patients central line after which they get into the bloodstream.
CLABSI related infections are often serious but they can be successfully managed through appropriate treatment approaches.
Femoral central venous catheters and internal jugular along with subclavian central lines have high risk of getting infected.
As per the survey conducted in 2019 about the central line bloodstream infections, it was found that the infection ratio for the said infections was 0.8 per 1000 central line days. This means that over 250000 people across the world bloodstream infections occur yearly and most of them are associated with the presence of intravascular devices.
2
Identification and description of the clinical issue.
Cont.………
Risk factors for Central Line-associated Bloodstream Infections (CLABSI)
presence of gastrostomy tube.
ICU placement of central venous catheter.
Immunosuppression.
Antibiotic therapy(Steffens et al., 2019,).
Poor nutrition;
Multiple invasive procedures.
nonoperative cardiovascular disease.
Central line bloodstream infection is associated with numerous predisposing risk factors. From healthcare stats, it can be said that central line catheters are the common causes of health callings linked to CLABSI. However there are many other risk factors that predispose patients to contracting or developing central line bloodstream infections. Contamination may occur within the central line and this may cause central line related illness. Such contamination include; non interact dressing, contaminated infusion, central venous access devices as well as patient's skin flora.
3
How to develop PICOT question for CLABSI
By analyzing the major components of PICOT, that is P-population, patients, or problem at hand, I-interventions required to solve the issue, C- control or alternative interventions to be compared, O-outcome or the objective to be achieved and T-time framework required to achieve desired outcome(Steffens et al., 2019).
This will help formulate questions such as;
Who and what is the issues that need to be addressed?
What is the proposed intervention and actions to remedy the issue?
What is desired outcome?
How much time is required to realized anticipated results?
To come up with PICOT statement of question on the clinical issues that I had chosen I had to analyze all the components of PICOT to identify their meanings so as to develop a questions that meets PICOT guidelines. The analysis of the PICOT components will help develop questions about the what are kind of population or patients affec ...
The 2019 Diagnostic Summit brought together diagnostic developers in academia and industry as well as end-users in the pharmaceutical and healthcare sector to gain a comprehensive picture of diagnostics in prenatal, oncology, infectious disease, point-of-care, and liquid biopsy.
This important Summit enabled delegates to learn what novel technologies, platforms and applications are emerging that will impact future healthcare delivery and pharmaceutical research.
Bringing together European leading experts via presentations, workshops and case studies the Summit was a must attend event! We explored:
Current diagnostic testing in GP surgeries and Pharmacies
How Diagnostics can be funded and funding barriers
Advances in Prenatal Molecular Diagnostics
Diagnostic Regulations
Point of care testing
Advanced Diagnostics for infectious diseases
Adapting and evaluating Innovation
Education on testing and accuracy
Patient and Clinical pathways
Key health areas examined in the Summit included:
Sexual Health
Diabetes
Cancer
Antibiotic Resistance
Sepsis
Obesity
Urinary Infections
SYSTEMS-LEVEL QUALITY IMPROVEMENTFrom Cues to Nudge A Knolisandrai1k
SYSTEMS-LEVEL QUALITY IMPROVEMENT
From Cues to Nudge: A Knowledge-Based Framework
for Surveillance of Healthcare-Associated Infections
Arash Shaban-Nejad1,2 & Hiroshi Mamiya2 & Alexandre Riazanov3 & Alan J. Forster4 &
Christopher J. O. Baker2,5 & Robyn Tamblyn2 & David L. Buckeridge2
Received: 3 June 2015 /Accepted: 30 September 2015 /Published online: 4 November 2015
# Springer Science+Business Media New York 2015
Abstract We propose an integrated semantic web framework
consisting of formal ontologies, web services, a reasoner and a
rule engine that together recommend appropriate level of
patient-care based on the defined semantic rules and guide-
lines. The classification of healthcare-associated infections
within the HAIKU (Hospital Acquired Infections – Knowl-
edge in Use) framework enables hospitals to consistently fol-
low the standards along with their routine clinical practice and
diagnosis coding to improve quality of care and patient safety.
The HAI ontology (HAIO) groups over thousands of codes
into a consistent hierarchy of concepts, along with relation-
ships and axioms to capture knowledge on hospital-associated
infections and complications with focus on the big four types,
surgical site infections (SSIs), catheter-associated urinary tract
infection (CAUTI); hospital-acquired pneumonia, and blood
stream infection. By employing statistical inferencing in our
study we use a set of heuristics to define the rule axioms to
improve the SSI case detection. We also demonstrate how the
occurrence of an SSI is identified using semantic e-triggers.
The e-triggers will be used to improve our risk assessment of
post-operative surgical site infections (SSIs) for patients un-
dergoing certain type of surgeries (e.g., coronary artery bypass
graft surgery (CABG)).
Keywords Ontologies . Knowledge modeling .
Healthcare-associated infections . Surveillance . Semantic
framework . Surgical site infections
Introduction
Healthcare-associated Infections (HAIs) affect millions of
patients around the world, killing hundreds of thousands
and imposing, directly or indirectly, a significant socio-
economic burden on healthcare systems [1]. According
to the Centers for Disease Control (CDC) [2], hospital-
acquired infections in the U.S., where the point preva-
lence of HAIs among hospitalized patients is 4 %, result
in an estimated 1.7 million infections, which lead to as
many as 99,000 deaths and cost up to $45 billion annually
[3, 4]. Similar or higher rates of HAI occur in other coun-
tries as well with an estimated 10.5 % of patients in Ca-
nadian hospitals having an HAI [5]. Clinical assessment
and laboratory testing are generally used to detect and
confirm an infection, identify its origin, and determine
appropriate infection control methods to stop the infection
from spreading within a healthcare institution. Failure to
monitor, and detect HAI in timely manner can delay di-
agnosis, leading to complications (e.g., sepsis), and
allowing an epid ...
SYSTEMS-LEVEL QUALITY IMPROVEMENTFrom Cues to Nudge A Kno.docxdeanmtaylor1545
SYSTEMS-LEVEL QUALITY IMPROVEMENT
From Cues to Nudge: A Knowledge-Based Framework
for Surveillance of Healthcare-Associated Infections
Arash Shaban-Nejad1,2 & Hiroshi Mamiya2 & Alexandre Riazanov3 & Alan J. Forster4 &
Christopher J. O. Baker2,5 & Robyn Tamblyn2 & David L. Buckeridge2
Received: 3 June 2015 /Accepted: 30 September 2015 /Published online: 4 November 2015
# Springer Science+Business Media New York 2015
Abstract We propose an integrated semantic web framework
consisting of formal ontologies, web services, a reasoner and a
rule engine that together recommend appropriate level of
patient-care based on the defined semantic rules and guide-
lines. The classification of healthcare-associated infections
within the HAIKU (Hospital Acquired Infections – Knowl-
edge in Use) framework enables hospitals to consistently fol-
low the standards along with their routine clinical practice and
diagnosis coding to improve quality of care and patient safety.
The HAI ontology (HAIO) groups over thousands of codes
into a consistent hierarchy of concepts, along with relation-
ships and axioms to capture knowledge on hospital-associated
infections and complications with focus on the big four types,
surgical site infections (SSIs), catheter-associated urinary tract
infection (CAUTI); hospital-acquired pneumonia, and blood
stream infection. By employing statistical inferencing in our
study we use a set of heuristics to define the rule axioms to
improve the SSI case detection. We also demonstrate how the
occurrence of an SSI is identified using semantic e-triggers.
The e-triggers will be used to improve our risk assessment of
post-operative surgical site infections (SSIs) for patients un-
dergoing certain type of surgeries (e.g., coronary artery bypass
graft surgery (CABG)).
Keywords Ontologies . Knowledge modeling .
Healthcare-associated infections . Surveillance . Semantic
framework . Surgical site infections
Introduction
Healthcare-associated Infections (HAIs) affect millions of
patients around the world, killing hundreds of thousands
and imposing, directly or indirectly, a significant socio-
economic burden on healthcare systems [1]. According
to the Centers for Disease Control (CDC) [2], hospital-
acquired infections in the U.S., where the point preva-
lence of HAIs among hospitalized patients is 4 %, result
in an estimated 1.7 million infections, which lead to as
many as 99,000 deaths and cost up to $45 billion annually
[3, 4]. Similar or higher rates of HAI occur in other coun-
tries as well with an estimated 10.5 % of patients in Ca-
nadian hospitals having an HAI [5]. Clinical assessment
and laboratory testing are generally used to detect and
confirm an infection, identify its origin, and determine
appropriate infection control methods to stop the infection
from spreading within a healthcare institution. Failure to
monitor, and detect HAI in timely manner can delay di-
agnosis, leading to complications (e.g., sepsis), and
allowing an epid.
Rivaroxaban with or without aspirin in patients with stable peripheral or car...Bhargav Kiran
Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
1. the bmj | BMJ 2016;355:i5813 | doi: 10.1136/bmj.i5813
RESEARCH
1
open access
1Department of Epidemiology
and Public Health, University of
Nottingham, Nottingham NG5
1PB, UK
2Department of Basic Medical
Sciences, King Saud bin
Abdulaziz University for Health
Sciences, Saudi Arabia
3NIHR Nottingham Digestive
Diseases Biomedical Research
Unit, Nottingham University
Hospitals NHS Trust and
University of Nottingham,
Nottingham, UK
Correspondence to: F Othman
msxfo1@nottingham.ac.uk
Additional material is published
online only. To view please visit
the journal online.
Cite this as: BMJ 2016;355:i5813
http://dx.doi.org/10.1136/bmj.i5813
Accepted: 18 October 2016
Community acquired pneumonia incidence before and after
proton pump inhibitor prescription: population based study
Fatmah Othman,1,2 Colin J Crooks,1 Timothy R Card1,3
ABSTRACT
Objective
To examine the risk of community acquired pneumonia
before and after prescription of proton pump inhibitor
(PPI) and assess whether unmeasured confounding
explains this association.
Design
Cohort study and self controlled case series.
Setting
Clinical Practice Research Datalink (1990 to 2013) in UK.
Participants
Adult patients with a new prescription for a PPI
individually matched with controls.
Main outcome measures
Association of community acquired pneumonia with
PPI prescription estimated by three methods: a
multivariable Cox model comparing risk in PPI exposed
patients with controls, corrected for potential
confounders; a self controlled case series; and a prior
event rate ratio (PERR) analysis over the 12 month
periods before and after the first PPI prescription.
Results
160 000 new PPI users were examined. The adjusted
Cox regression showed a risk of community acquired
pneumonia 1.67 (95% confidence interval 1.55 to 1.79)
times higher for patients exposed to PPI than for
controls. In the self controlled case series, among
48 451 PPI exposed patients with a record of
community acquired pneumonia, the incidence rate
ratio was 1.19 (95% confidence interval 1.14 to 1.25) in
the 30 days after PPI prescription but was higher in the
30 days before a PPI prescription (1.92, 1.84 to 2.00).
The Cox regressions for prior event rate ratio similarly
showed a greater increase in community acquired
pneumonia in the year before than the year after PPI
prescription, such that the analysis showed a reduced
relative risk of pneumonia associated with PPI use
(prior event rate ratio 0.91, 95% confidence interval
0.83 to 0.99).
Conclusion
The association between the use of PPIs and risk of
community acquired pneumonia is likely to be due
entirely to confounding factors.
Introduction
Proton pump inhibitors (PPIs) have become the corner-
stone of medical treatment for acid related gastrointes-
tinal disorders. The widespread use of PPI treatment in
clinical settings means that even if the health risks
associated with their use are modest, they could have a
substantial effect on a large number of patients.1 2 One
of the adverse outcomes associated with PPI use that
has attracted a considerable amount of attention in
existing research is the possible increase in the risk of
pneumonia.3-7 This association has been hypothesised
to be related to bacterial overgrowth and colonisation
as a result of alteration of the acidity of the stomach.4 5
Meta-analyses of randomised controlled trials have
shown that the use of PPIs to prevent stress ulcers may
increase the risk of hospital acquired pneumonia in
critically ill patients.8 9 However, in the context of com-
munity acquired pneumonia, which is a common cause
of morbidity and mortality especially among older peo-
ple and those with other medical comorbidities,10 this
link has been inconsistent in previous observational
studies.11-16 These studies have been criticised for a lack
of control for unmeasured confounding (such as
patients’ characteristics and comorbidities)17 and bias
(such as confounding by indication)18 that may impair
the significance of the association.
In the absence of data from randomised controlled
trials, the variation in the risk of community acquired
pneumonia among PPI users compared with non-users
in previous studies may be attributable to differences
between the groups in known and unknown risk fac-
tors. Advances in analytical techniques may enhance
the validity of the results of observational studies by
attempting to mitigate some of the effects of hidden
confounding. We therefore aimed to assess whether
confounding explains the association between the use
of PPIs and the risk of community acquired pneumonia
by using appropriate analytical techniques on observa-
tional data.
Methods
Data source
We used the Clinical Practice Research Datalink
(CPRD), a large UK based electronic database of primary
care records (www.cprd.com).19 CPRD has been exten-
sively used and validated for pharmacoepidemiology
research.19-21 The database contains anonymised infor-
mation about patients that encompasses medical diag-
noses, prescriptions, investigations, and referrals to
What is already known on this topic
Studies have suggested that patients who are treated with proton pump inhibitors
(PPIs) have an increased risk of developing community acquired pneumonia
Potential confounders and bias may impair the interpretation of the association
that has been observed in these studies
What this study adds
The crude association between PPI prescriptions and an increased rate in community
acquired pneumonia could be explained by an underlying increased riskof pneumonia
The confounding factors present before PPI use, rather than PPI use itself, were the
main contributors to an increased rate of community acquired pneumonia in
patients receiving PPIs
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RESEARCH
2
secondary care. More than 50% of the practices that
include their records in the CPRD have consented to
their patients’ records being linked with Hospital Epi-
sode Statistics data and Office for National Statistics
mortality data.19 Hospital Episode Statistics data con-
tain information on all patients who have been admit-
ted to hospital, together with information about the
primary and secondary causes of each episode of inpa-
tient care (with diagnosis coded using ICD-10 (interna-
tional classification of diseases, 10th revision)), type of
admission, procedure performed, length of stay, and
discharge status.22
Study population
The study population included people aged 18 years or
over and registered in the CPRD from 1 January 1990 to
1 August 2013. Patients had to have at least one year of
registration on CPRD after the later of the date of cur-
rent registration and the date the practice became “up
to standard” on CPRD,21 as well as an “acceptable” reg-
istration status as defined by CPRD.21 We identified an
exposed cohort from this source population as a ran-
dom sample of 160 000 people who received a first pre-
scription for a PPI in CPRD at least one year after they
started contributing data during the study period (that
is, new users). We calculated the duration of each PPI
prescription by using the number of treatment days
recorded by the general practitioner or dividing the
total prescription quantity by the numeric daily dose
prescribed for each prescription.
We also identified a subset of patients with linked
Hospital Episode Statistics/Office for National Statistics
data within the study population and selected these
patients to improve the ascertainment of the outcome of
this study (that is, community acquired pneumonia).
For this subset, we looked specifically at patients with
more severe community acquired pneumonia requiring
hospital admission by limiting the definition of pneu-
monia to those coded within Hospital Episode Statis-
tics/Office for National Statistics data. We also modified
the follow-up period to be consistent with the linkage
coverage period (from January 1998 to January 2012).
Outcome
We defined community acquired pneumonia in the
CPRD by the presence of a Read code for this diagnosis
(list of codes available on request). The list included
codes for chest infection and lower respiratory tract
infection to ensure that all cases of community acquired
pneumonia categorised in this way were captured. We
refer to this as our broad primary care definition and
also used a narrow primary care definition eliminating
codes not specific for pneumonia. We regarded pneu-
monia diagnoses recorded less than 84 days apart as
the same event, as we considered 84 days to be suffi-
cient for the clinical condition and lung function to
have returned to the baseline state.23 24 For patients with
Hospital Episode Statistics/Office for National Statistics
linked data, we identified episodes of hospital admis-
sion that were allocated a primary diagnosis of commu-
nity acquired pneumonia or a death certificate that was
issued between March 1997 and April 2012 on which
pneumonia was listed as a contributing or underlying
cause of death (on the basis of ICD coding).
Study design
We used self controlled case series and cohort study
designs in this study.
Self controlled case series study
The self controlled case series analysis method is a type
of cohort study in which relative risk is based on within
person comparisons between exposed and unexposed
observation time, so only exposed patients with events
can be included.25 The advantage of this design is that
the influence of between person confounding will be
eliminated.25 26 From the cohort exposed to PPIs, we
selected all the cases with a recorded diagnosis of com-
munity acquired pneumonia. We considered the expo-
sure to PPIs to begin on the date of PPI prescription and
to end after its calculated duration including any con-
secutive prescriptions, plus an additional 30 day wash-
out period. We then divided the observation time into
risk windows for each person: 30 days before starting
the first PPI prescription; 0-30 days after starting the
first PPI prescription; and the remaining exposed
period with the post-exposure 30 day period. The base-
line (unexposed) period consisted of all observation
times for which no PPI prescription was issued within
the study period (fig 1). The purpose of the additional 30
day period before the first prescription was to assess
whether any increase in community acquired pneumo-
nia rate was associated with an acute event that might
have precipitated the PPI prescription.
Baseline period (no PPI prescription)
Start of
observation
period
End of
observation
period
First PPI
prescription
End of PPI
course
Start of second
PPI course
Pre-exposure period (30 days before first PPI prescription)
30 days exposure period (30 days after first PPI prescription)
Remaining exposure period
Fig 1 | Illustration of self controlled case series method showing division of time of each person included in this analysis to
assess incidence of community acquired pneumonia in relation to prescription for proton pump inhibitor (PPI). Events of
pneumonia can occur during baseline or exposure period
3. the bmj | BMJ 2016;355:i5813 | doi: 10.1136/bmj.i5813
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3
Cohort study
For this study design, we individually matched the
exposed patients one to one by age (within 5 years), sex,
and year of prescription with an unexposed cohort who
had never received a PPI prescription. We required these
unexposed controls also to have been contributing data
for at least one year before their matched patient’s first
prescription. The following potential confounders were
extracted and evaluated from the CPRD primary care
record, both for all CPRD patients and for the subset of
patients with Hospital Episode Statistics/Office for
National Statistics linked data: smoking status (catego-
rised into smoker, never smoked, or missing), alcohol use
(never drinker, ever drinker, or missing), number of visits
to the general practitioner in the year before the PPI pre-
scription (five visits or fewer, or more than five visits),
immunosuppression(definedaschemotherapytreatment
withintheprevioussixmonths,systemichighdosesteroid
treatmentforthreemonths,receiptofcertainimmunosup-
pressive drugs, having a solid organ transplant with any
anti-rejection drugs in the previous year, or having a diag-
nosis of HIV infection27 ), and comorbidities categorised
on the basis of the Charlson index score.28 We assessed
comorbiditiesbyusingtheentirepatientrecordbeforethe
first PPI prescription date for the exposed cohort or the
matched date for the unexposed cohort. We also included
prescriptionsofsystemiccorticosteroidandopioid(within
90 days before the prescription or matched date). In addi-
tion, we included data on the socioeconomic status mea-
sured using the Index of Multiple Deprivation 2007.
Statistical analyses
We calculated descriptive summary statistics for the
study population by exposure status. We then did the
analyses below, both for all CPRD patients and for the
subset of patients with Hospital Episode Statistics/
Office for National Statistics linked data. For each anal-
ysis, we present results for our three different defini-
tions of community acquired pneumonia (broad
primary care definition, narrow primary care definition,
and hospital and mortality records based definition).
We used the same cohort across the study designs to
avoid using multiple cohorts, because this may cause
confusion when comparing the study results. We used
Stata 12 for all statistical analyses.
Self controlled case series analysis
We used conditional Poisson regression models with
fixed effects to calculate the incidence rate ratio com-
paring the incidence rate of community acquired pneu-
monia during the exposure period with the incidence
rate during the baseline period, with adjustment for age
(5 year bands).25 26 This allows inclusion of multiple
events of pneumonia during the observation period and
adjusts for the correlations within individuals. Thus,
the data were expanded to panel data, so that each row
corresponded to a single time interval for each case. We
then identified the numbers of events that occurred
within each interval. We excluded person time after the
pneumonia event until the day after the date of resolu-
tion of pneumonia, because no additional events could
occur until the current pneumonia had resolved.
Cohort study
We did two analyses using this study design: a multi-
variable Cox proportional hazards analysis and a prior
event rate ratio analysis.29-31
In the adjusted Cox regression analysis, we considered
the first occurrence of community acquired pneumonia
after the index date. We used Cox proportional hazards
modelling to estimate the hazard ratio for pneumonia in
people receiving PPIs, adjusted for potential confound-
ers, with 95% confidence intervals. We followed the
cohorts from the date of their first PPI prescription until
theearliestofthepneumoniaeventdate,prescriptionend
date, or study end date (this was the earliest date of the
following:endofobservationtime(1August2013),dateof
death, date transferred to a different practice, or last date
of data collection from practice). We tested the validity of
the proportional hazards assumption by plotting log-mi-
nus-logsurvivalcurvesandcarryingoutSchoenfeldtests.
We included each potential confounder in the model if
they modified the hazard ratio by more than 10%. We cat-
egorised missing data into a separate category.
The prior event rate ratio adjustment method has
recently been proposed as a means of reducing the bias
that results from residual confounding.29-31 This method
requires that both exposed and unexposed cohorts did
not receive the study drug before the index date—that is,
the date at which the exposed cohort first received the
prescription and the matched date for the unexposed
patients. The method relies on a before and after design
and is based on the assumption that the differences in
outcomes between exposed and unexposed patients
before receiving the treatment reflect the combined effect
of confounders independently of any effect of the study
drug.29 31 The prior event rate ratio is estimated by the
ratio of two unadjusted hazard ratios: the unadjusted
hazard ratio for community acquired pneumonia during
the year after initial PPI prescription for the exposed
group versus the unexposed group (HR.post) and the
unadjusted hazard ratio for community acquired pneu-
monia before the PPI prescription of the exposed versus
the unexposed people (HR.prior)—prior event rate ratio
adjusted hazard ratio=HR.post/HR.prior (fig 2 ). There-
fore, the prior event rate ratio provides an estimate of the
effect the drug exposure had on the hazard adjusted for
Follow-up time
PPI exposure
Hazard ratio prior reflects
differences in pneumonia risk
Hazard ratio post reflects differences
in pneumonia risk and PPI effect
Post-exposure periodPrior-exposure period
Exposed patients
Non-exposed patients
Fig 2 | Prior event rate ratio adjustment method. Prior period means time before index date
(proton pump inhibitor (PPI) prescription date for exposed cohort and matched date for
unexposed patients); post period means time after PPI exposure
4. doi: 10.1136/bmj.i5813 | BMJ 2016;355:i5813 | the bmj
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4
confounding.31 The follow-up of patients in the year after
initial PPI prescription ran from the date of their first PPI
prescription until the earliest of the anniversary of that
date, the occurrence of a pneumonia event, or the study
end date. For the year before the initial PPI prescription,
patients were followed from the date one year before
starting the PPI until the earliest of a pneumonia event or
the start of the PPI. We obtained the 95% confidence
intervalsoftheprioreventrateratiobybootstrapping.29 31
Sensitivity analyses
As with any statistical method, several assumptions must
bemetforboththeselfcontrolledcaseseriesanalysisand
prior event rate ratio analysis methods to be considered
reliable. We did sensitivity analyses to assess the possibil-
ity that these assumptions had been violated. For the self
controlled case series, the first assumption is that the
occurrence of recurrent outcome events must be indepen-
dent—that is, the occurrence of one event must not alter
the probability of a subsequent event occurring.25 We did
asensitivityanalysisrestrictedtothefirsteventofcommu-
nityacquiredpneumoniaduringtheobservationperiodto
assessthisassumption.Thesecondassumptionoftheself
controlled case series, as well as for prior event rate ratio,
was that the occurrence of one event should not alter the
probability of subsequent exposure.25 31 Although pneu-
moniaisnotarecognisedindication,caution,orcontrain-
dication for the use of PPIs, it is likely that hospital
admission could lead to the prescription of a PPI.32 To
account for this, we did an analysis that was limited to
new users of PPIs who had not been admitted to hospital
in the 60 days before the first PPI course. The third
assumption is that mortality subsequent to an event
should not alter the probability of subsequent expo-
sure.26 31 Fortheselfcontrolledcaseseriesanalysis,wedid
a sensitivity analysis that excluded people who had died
within90daysoftherecordedcommunityacquiredpneu-
monia, as such cases could have used PPIs only before
communityacquiredpneumoniaandnotafterwards.Sim-
ilarly, for the prior event rate ratio analysis, we did sensi-
tivity analysis restricted to non-fatal pneumonia on the
basis that it would be impossible for fatal pneumonia
cases to occur in the one year before the first PPI prescrip-
tion, whereas fatal pneumonia could occur afterwards.
Also, we carried out a sensitivity analysis that was limited
tocasesbeforethepointatwhichthefirstlargepopulation
based study suggesting an association was published in a
specialised medical journal,11 to minimise the risk that
knowledge of patients’ PPI use could affect diagnosis of
pneumonia or that previous pneumonia events could
affect the physician’s decision to prescribe a PPI.
For the Cox regression analysis and prior event rate
ratio, we did a sensitivity analysis restricted to people
over the age of 65 years (who are eligible to receive free
prescriptions and therefore were less likely to purchase
over the counter drugs) and to the time period before
the availability of the over counter PPIs in the UK.33
Sample size calculation
We used the stpower Cox command to calculate the
minimum number of events needed to detect a hazard
ratio of 1.1 with 90% power and α=0.05. With an esti-
mated incidence rate of 0.6 per 100 unexposed person
years,11 23 we estimated that 160 000 patients were
needed assuming an average five year follow-up period
for each patient and constant pneumonia risk over cal-
endar time. This study population of 160 000 PPI
exposed patients, therefore, was randomly sampled
from the whole CPRD population according to the
power calculation outlined above.
Patient involvement
No patients were involved in the development of the
research question or the outcome measures. No patients
were involved in developing plans for recruitment,
design, or implementation of the study, nor were they
asked to advice on interpretation or writing up of
results. There are no plans to disseminate the results of
the research to study participants.
Results
We identified 160 000 new users of PPIs during the
study period who were matched individually to an
equal number of non-PPI exposed patients. The mean
age at entry to the study was 56 (SD 16) years for both
exposed and unexposed cohorts, and 55% (n=88 455) of
each cohort were women. Compared with unexposed
patients, those prescribed PPIs were more likely to have
a history of smoking (42.9% v 33.7% of their matched
controls) and alcohol use (29.1% v 23.9%); they also had
a higher burden of comorbidity and used more cortico-
steroids and opioids (table 1 ). Hospital Episode Statis-
tics/Office for National Statistics linked information
was available for 257 886 of the patients, whose
characteristics were largely similar to those of the com-
plete cohort (table 1). Most patients used PPIs for a
short period, with a median duration of 28 (interquar-
tile range 28-76) days.
Cox regression analysis
In this analysis, the exposed patients had an
increased hazard of pneumonia defined by each of the
three definitions of community acquired pneumonia.
Hazard ratios were greater when we defined commu-
nity acquired pneumonia more narrowly, with unad-
justed hazard ratios of 5.44 (95% confidence interval
4.23 to 6.99) and 4.76 (4.12 to 5.49) when we used nar-
row primary care definitions and hospital/mortality
records based definitions, respectively (table 2 ). After
adjustment, the hazard of pneumonia by our broad
primary care definition fell to 1.67 (1.55 to 1.79) times
that of controls in PPI exposed patients, and the haz-
ard ratios were similarly reduced by adjustment for
confounding when our narrower primary care defini-
tions of pneumonia were used (table 2 ). In each case,
however, we found a statistically significant excess of
pneumonia in the exposed cohort. As the Charlson’s
index was developed to predict mortality and not
morbidity, we carried out a separate analysis adjusted
for individual important potential confounders for
pneumonia that resulted in a slight reduction in the
hazard ratio (table 2).
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Self controlled case series
From the exposed cohort, we identified 48 451 PPI
exposed patients in CPRD with a record of at least one
community acquired pneumonia (broad primary care
definition), with a mean age of 60 (SD 16) years, and
5582 patients in Hospital Episode Statistics linked data
who had a record of pneumonia related to hospital
admission or death, with mean age of 70 (SD 14) years.
Table 3 shows the incidence rate ratios for the differ-
ent risk windows and pneumonia definitions. Using our
broad definition, the incidence rate ratio for pneumonia
among PPI users was 1.19 (1.14 to 1.25) for 30 days after
PPI prescription and 1.49 (1.46 to 1.52) for the remaining
exposure period compared with the baseline period
(table 3 ). The incidence rate ratio for the 30 days before
exposure was even higher at 1.92 (1.84 to 2.00). As for
the Cox regression, differences in ratios were higher for
the more narrow definition of pneumonia (table 3).
Prior event rate ratio analysis
The rate of pneumonia for the exposed patients was
similar before a PPI prescription (62.1 per 1000 person
years of follow-up) to the rate after a PPI prescription
(61.4 per 1000 person years of follow-up), whereas the
rate of pneumonia in unexposed patients increased
over the study period (table 4 ). The prior event rate
Table 1 | Demographic and clinical characteristics of study population included in cohort
study by exposure status at cohort entry into study period, for all CPRD patients and for
subset of patients with HES-ONS linked data. Values are numbers (percentages)
Characteristic
Complete cohorts
(n=320 000)
HES-ONS linked patients
(n=257 886)
Unexposed
(n=160 000)
Exposed
(n=160 000)
Unexposed
(n=128 943)
Exposed
(n=128 943)
Smoking:
Never smoked 59 581 (37.2) 57 805 (36.1) 47 243 (36.7) 45 757 (35.5)
Smoker 53 889 (33.7) 68 612 (42.9) 43 633 (33.8) 55 935 (43.4)
Missing 46 530 (29.1) 33 583 (21.0) 38 067 (29.5) 27 251 (21.1)
Alcohol use:
Never drinker 48 961 (30.6) 51 747 (32.3) 40 394 (31.3) 42 716 (33.1)
Ever drinker 38 292 (23.9) 46 524 (29.1) 29 364 (22.8) 36 246 (28.1)
Missing 72 747 (45.5) 61 729 (38.6) 59 185 (45.9) 49 981 (38.8)
Index of Multiple Deprivation fifths*:
Unavailable 4833 (3.0) 4333 (2.7) 24 (0.02) 26 (0.02)
1 (least deprived) 41 096 (25.7) 36 149 (22.6) 34 359 (26.6) 29 987 (23.3)
2 37 827 (23.6) 36 504 (22.8) 31 588 (24.5) 30 236 (23.4)
3 30 651 (19.2) 30 904 (19.3) 25 464 (19.8) 25 739 (20.0)
4 27 332 (17.1) 30 002 (18.8) 22 542 (17.5) 24 867 (19.3)
5 (most deprived) 18 261 (11.4) 22 108 (13.8) 14 966 (11.6) 18 088 (14.0)
Charlson comorbidity index score:
0 99 492 (62.2) 72 290 (45.2) 79 978 (62.0) 58 048 (45.0)
1-2 48 287 (30.2) 63 461 (39.7) 39 124 (30.4) 51 098 (39.6)
3-4 9510 (5.9) 17 494 (10.9) 7775 (6.0) 14 413 (11.2)
>5 2711 (1.7) 6755 (4.2) 2066 (1.6) 5384 (4.2)
No of general practitioner visits:
≤5 87 286 (54.5) 37 605 (23.5) 69 788 (54.1) 29 582 (22.9)
>5 72 714 (45.4) 122 395 (76.5) 59 155 (45.9) 99 361 (77.1)
Immunosuppression† 4882 (3.0) 16 609 (10.3) 3866 (3.0) 13 723 (10.6)
Non-topical corticosteroid use 5832 (3.6) 15 990 (9.9) 4814 (3.7) 13 221 (10.2)
Opioid prescriptions 1557 (0.9) 9469 (5.9) 1261 (0.9) 7809 (6.0)
CPRD=Clinical Practice Research Datalink; HES=Hospital Episode Statistics; ONS=Office for National Statistics.
*Socioeconomic status is based on Index of Multiple Deprivation; values are percentage of people who had
deprivation status available.
†Immunosuppressed patients defined according to criteria to contraindicate vaccination.27
Table2|Adjustedandunadjustedhazardratiosand95%confidenceintervalsforassociationofcommunityacquiredpneumoniawithprotonpumpinhibitors(PPI)accordingtothreedifferent
definitionsofcommunityacquiredpneumonia(Coxregressionanalysis)
Parameter
Pneumoniadefinition
BroadprimarycaredefinitionNarrowprimarycaredefinition
Hospitalandmortalityrecordsbased
definition(inHES/ONSlinkedpatients)
UnexposedExposedUnexposedExposedUnexposedExposed
Noofpatientsmatchedfordate,sex,and5yearageband160 000160 000160 000160 000128 943128 943
Noofpneumoniaevents15823798743922341090
Personyearsoffollow-up52 13349 88552 13349 88543 82443 456
Rateofpneumoniaper1000personyears(95%CI)30.34(28.88to31.87)76.13(73.75to78.59)1.37(1.09to1.73)7.31(6.62to8.07)5.48(4.82to6.23)25.74(24.26to27.32)
Unadjustedhazardratio(95%CI)2.51(2.36to2.67)5.44(4.23to6.99)4.76(4.12to5.49)
Adjustedhazardratio*(95%CI)1.67(1.55to1.79)3.73(2.69to5.16)3.55(3.03to4.16)
Adjustedhazardratio†(95%CI)1.65(1.53to1.77)3.87(2.75to5.44)3.54(3.02to4.16)
HES=HospitalEpisodeStatistics;ONS=OfficeforNationalStatistics.
*ModeladjustedforconfoundersthatchangedPPIhazardratioby>10%:(comorbidityindex,numberofgeneralpractitioner(GP)visits,corticosteroiduse,andimmunosuppression).
†Modeladjustedforpotentialconfoundingvariablesforpneumonia(malignancy,cerebrovasculardisease,hemiplegia,chronicpulmonarydisease,congestivecardiacdisease,lymphoproliferativedisorders,dementia,diabetes,renaldisease,
rheumatologicaldisease,myocardialinfarction,andliverdisease),inadditiontonumberofGPvisits,corticosteroiduse,andimmunosuppression.
7. the bmj | BMJ 2016;355:i5813 | doi: 10.1136/bmj.i5813
RESEARCH
7
ratio for pneumonia (broad primary care definition)
was 0.91 (0.83 to 0.99) on the basis of an unadjusted
post-PPI hazard ratio of 2.06 (1.98 to 2.14) divided by an
unadjusted prior-PPI hazard ratio of 2.26 (2.18 to 2.35).
Similarly, the prior event rate ratio for pneumonia in
Hospital Episode Statistics/Office for National Statistics
subset was 0.74 (0.69 to 0.97) (table 4).
Sensitivity analysis
For the self controlled case series analysis, restricting
the primary analysis to only the first event recorded
resulted in reductions in the observed rate ratios of
pneumonia after PPI prescriptions, whereas no change
was seen in the risk of pneumonia before the PPI pre-
scription (supplementary table A). After exclusion of
the 20% of patients in the self controlled case series
analysis who had been admitted to hospital before their
first PPI prescription, the incidence rate ratio for com-
munity acquired pneumonia (using our broad primary
care definition of pneumonia) was very little changed
from that of our primary analysis (supplementary table
B). Around 5% of patients died within 90 days of the
date of diagnosis of pneumonia, and the results of the
analysis excluding these patients showed a reduction in
the incidence rate ratio for pneumonia for 30 days after
PPI prescription and for the remaining exposure period
(supplementary table C).
For the prior event rate ratio method, both of the
analyses to test for a possible violation of the underly-
ing assumption concerning the effect of hospital admis-
sion on the probability of subsequent PPI exposure and
the effect of mortality produced similar results to the
primary analysis (supplementary tables D and E). The
results from the remaining sensitivity analyses were
very similar to those from the whole population for Cox
regression and prior event rate ratio analyses (supple-
mentary tables F-J).
Discussion
This study has shown that a crude association exists
between PPI prescriptions and an increased rate of
community acquired pneumonia, but that this is
explained by an underlying increased risk of pneumo-
nia in patients preceding a PPI prescription. Further-
more, after adjustment for confounding and changes
over time, the relative rate of community acquired
pneumonia actually fell after PPI prescriptions.
Strengths and limitations of study
A major strength of this study is that we have used rou-
tinely collected general practice records to conduct it.
This provides for an unbiased selection of both the
exposed and control cohorts and reduces the opportu-
nity for information bias (as both PPI prescription and
pneumonia diagnosis were prospectively collected
independently). In addition, as the base population is
representative of the UK general population, our results
are likely to be generalisable at least to the UK popula-
tion and to other similar populations.21 However, the
generalisability of self controlled case series analysis is
limited, as patients who are included may have a
different underlying risk of community acquired pneu-
monia than the baseline population.
A further strength is that data were available relating
to several potential confounders, allowing us to control
for the effects of these in the Cox regression models.
However, missing data with respect to smoking and
alcohol use show a risk of residual confounding by
these factors in addition to unmeasured confounding.
An important methodological strength therefore is that
we have used two analytical methods to mitigate the
effect of confounders that are difficult to measure or
incompletely measured.
We used the same patients as their own control in the
case series method to minimise confounding due to
patients’ characteristics and comorbidities. The condi-
tional Poisson regression model represented an effec-
tive choice in our analysis of recurrent events of
community acquired pneumonia because previous
studies have shown it to be effective in terms of the
over-dispersion and autocorrelation of panel data.34 35
Also, we examined the key assumptions underlying the
self controlled case series method by looking for evi-
dence that the occurrence of pneumonia does not alter
the risk of subsequent PPI prescription. Excluding from
the main analyses those patients who had been admit-
ted to hospital or died after pneumonia events had no
substantial effect on the results. However, as this
method adjusts for a fixed relative difference in con-
founders between the exposed and unexposed cohorts,
it does not reduce confounding due to factors that may
vary over time differently between the exposed and
unexposed people.
We also attempted to overcome the limitations of pre-
vious observational work by using a newer analytical
technique, prior event rate ratio, which has been
proposed as a method of controlling for unmeasured
time-fixed confounding.29 31 With this method, we were
able to adjust both for the underlying increased risk of
pneumonia in patients who were treated with PPIs (that
confounded a standard Cox regression) and for changes
in pneumonia incidence over time (that may have con-
founded the case series analysis). Although prior event
rate ratio methods offer a promising approach to over-
come biases that can arise in observational studies, in
practice we cannot exclude all situations in which pre-
vious events might influence future treatments. How-
ever, we attempted to assess the potential biases
carefully by examining the possible causes of violations
of the prior event rate ratio assumptions via either hos-
pital admission, death, or the publication of studies of
pneumonia risks influencing PPI prescriptions, and we
found no evidence to suggest that prior event rate ratio
represented an inappropriate analytical technique in
our study.
One potential limitation is the possibility of error in
our assessment of exposure, as CPRD data includes
only information about the prescriptions and does not
prove that the prescribed drug has been taken. This
could lead to exposure misclassification, especially in
the case of patients who took PPI intermittently. How-
ever, as PPIs are initially prescribed for symptom
8. doi: 10.1136/bmj.i5813 | BMJ 2016;355:i5813 | the bmj
RESEARCH
8
control, this may not lead to a large overestimation.
Additionally, previous studies reported that relying on
prescription information as a surrogate for PPI use is
unlikely to introduce significant misclassification.14
Although the information contained in the CPRD has
been validated for a wide range of diagnoses, including
other respiratory disease36 —and in particular the diag-
nosis of pneumonia in the linked CPRD-Hospital Epi-
sode Statistics data has been examined10—general
practitioners often diagnose community acquired
pneumonia without a radiograph, which may lead to
misclassification between this and other conditions (for
example, chest infection or chronic respiratory tract
infection). We tried to reduce the effect of such misclas-
sification by using more specific diagnostic codes for
community acquired pneumonia (using our narrow
definition) and by an analysis limited to patients with
hospital or death certificate diagnoses in the sensitivity
analyses.
Comparison with existing literature
Many studies have examined the association between
PPI treatment and the risk of community acquired
pneumonia. Early observational studies showed that
using PPIs might be associated with an increased risk of
community acquired pneumonia.11-13 Further studies
suggested that a dose-response relation supported cau-
sality of the association,11 16 and yet others argued that
a temporarily increased risk suggested the presence of
protopathic bias.17 18 There have also been studies
including a retrospective analysis of the original safety
data from several randomised clinical trials of esome-
prazole (one specific PPI),37 which failed to show any
such association despite statistical adjustment for con-
founders.14 15 Concern was amplified, however, by
findings from meta-analyses based on these observa-
tional studies that showed that the risk of community
acquired pneumonia was 34-49% higher among
patients who used PPIs than it was among non-users,
with a temporal relation soon after the start of the PPI
treatment.5 7 Thus, evidence linking PPI treatment to
the risk of community acquired pneumonia remains
inconclusive.
We have examined the association of PPI use and
community acquired pneumonia and assessed whether
residual and time-fixed confounding explains this asso-
ciation. The results of the adjusted Cox regression model
in this study did not differ from either the early observa-
tional studies or previous studies that used CPRD data
and found a similar association. However, self con-
trolled case series analysis shows that this risk predates
prescription, and the prior event rate ratio analysis sug-
gests that the significant association observed can be
attributed to confounding. Previous studies have
reported that the highest risk of pneumonia occurs in
the first 30 days, whereas we observed an incidence rate
ratio of 1.19 in the 30 days after PPI prescription and 1.49
for the remaining exposure period. This apparent con-
tradiction may be explained by differences in the sub-
populations of patients taking long term and short term
PPIs; as most courses in our data were short term, the
initial 30 days will primarily reflect these patients
whereas the later period will be long term users.
Our findings from the prior event rate ratio analysis
are comparable to those of a recent study that analysed
the pooled adverse event data related to respiratory
tract infection reported in randomised double blind
clinical studies that were specific to esomeprazole.38
The reported relative risk for pneumonia in patients
receiving esomeprazole compared with the placebo in
that study was 0.66 (95% confidence interval 0.36 to
1.22).38 Although the populations recruited to ran-
domised controlled trials are often not typical of those
receiving PPIs in general practice, our results suggest
that these findings may well be widely generalisable.
We believe that this comparison is also an important
validation of the prior event rate ratio method, which
has had limited use previously.
Conclusion
Our results indicate that no strong evidence exists to
support the association between the use of PPIs and an
increase in the risk of community acquired pneumonia.
Patients who are treated with PPIs have an underlying
risk of community acquired pneumonia before receiv-
ing the PPI prescription. Therefore, patients’ character-
istics, comorbidity, and severity of gastro-oesophageal
reflex disease were probably the main contributors to
the increased risk of pneumonia observed in patients
who received PPIs.17 18
Contributors: TRC proposed the original idea for the study, planned
the study design and the analysis, was involved in interpretation of
results, and revised the paper critically. FO helped in planning the
analysis and was responsible for data management, statistical
analyses, and writing the first draft of the paper. CJC contributed to
study design and concept, analysis planning, and interpretation of
results, as well as to revising the drafts of the paper. All authors
approved the final version. FO is the guarantor.
Funding: FO carried out this study as part of her PhD programme at
the University of Nottingham. She is a staff member at King Saud bin
Abdulaziz University for Health Sciences (KSAU-HS), Saudi Arabia. She
has received a scholarship award from KSAU-HS, which sponsors her
studies at University of Nottingham. The KSAU-HS had no role in the
design, analysis, data interpretation, or preparation of this manuscript.
TRC and CJC were independent of the funder.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare that: FO has
received a scholarship award from King Saud bin Abdulaziz University
for Health Sciences, Saudi Arabia, which sponsors her studies at the
University of Nottingham; no financial relationships with any
organisations that might have an interest in the submitted work in the
previous three years; no other relationships or activities that could
appear to have influenced the submitted work .
Ethical approval: This study was approved by the Independent
Scientific Advisory Committee (ISAC) with CPRD number 13_215.
Data sharing: CPRD data were provided under a licence that does not
permit sharing. Data are, however, obtainable directly from CPRD
under their standard conditions.
Transparency: The lead author affirms that the manuscript is an
honest, accurate, and transparent account of the study being reported;
that no important aspects of the study have been omitted; and that
any discrepancies from the study as planned (and, if relevant,
registered) have been explained
This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,
which permits others to distribute, remix, adapt, build upon this work
non-commercially, and license their derivative works on different terms,
provided the original work is properly cited and the use is non-
commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.
9. RESEARCH
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Supplementary tables