Nursing Workload as a Risk Factor for Healthcare Associated Infections in ICU: A Prospective Study

Introduction

Nurse understaffing is frequently hypothesized as a potential risk factor for healthcare-associated infections (HAI). This study aimed to evaluate the role of nursing workload in the occurrence of HAI, using Nursing Activities Score (NAS).

Methods

This prospective cohort study enrolled all patients admitted to 3 Medical ICUs and one step-down unit during 3 months (2009). Patients were followed-up until HAI, discharge or death. Information was obtained from direct daily observation of medical and nursing rounds, chart review and monitoring of laboratory system. Nursing workload was determined using NAS. Non-compliance to the nurses’ patient care plans (NPC) was identified. Demographic data, clinical severity, invasive procedures, hospital interventions, and the occurrence of other adverse events were also recorded. Patients who developed HAI were compared with those who did not.

Results

195 patients were included and 43 (22%) developed HAI: 16 pneumonia, 12 urinary-tract, 8 bloodstream, 2 surgical site, 2 other respiratory infections and 3 other. Average NAS and average proportion of non compliance with NPC were significantly higher in HAI patients. They were also more likely to suffer other adverse events. Only excessive nursing workload (OR: 11.41; p: 0.019) and severity of patient’s clinical condition (OR: 1.13; p: 0.015) remained as risk factors to HAI.

Conclusions

Excessive nursing workload was the main risk factor for HAI, when evaluated together with other invasive devices except mechanical ventilation. To our knowledge, this study is the first to evaluate prospectively the nursing workload as a potential risk factor for HAI, using NAS.     

Risk of Developing Depressive Disorders following Rheumatoid Arthritis: A Nationwide Population-Based Study

Background & Aims

To evaluate the risk of depressive disorders among rheumatoid arthritis (RA) by using the Taiwan National Health Insurance Research Database (NHIRD).

Methods

We conducted a retrospective study of a matched cohort of 18 285 participants (3 657 RA patients and 14 628 control patients) who were selected from the NHIRD. Patients were observed for a maximum of 10 years to determine the rates of newly diagnosed depressive disorders, and Cox regression was used to identify the risk factors associated with depressive disorders in RA patients.

Results

During the 10-year follow-up period, 205 (11.2 per 1000 person-years) RA patients and 384 (5.1 per 1000 person-years) control patients were diagnosed with depressive disorders. In RA patients, most depressive disorders (n = 163, 80%) developed with five years of being diagnosed with RA. The incidence risk ratio of depressive disorders between RA patients and control patients was 2.20 (95% confidence interval [CI], 1.84–2.61, P<.001). After adjusting for age, sex, and comorbidities, RA patients were 2.06 times more likely to develop depressive disorders (95% CI, 1.73–2.44, P<.001) compared with the control patients. Hyperthyroidism (HR = 1.67) was an independent risk factor for depressive disorders in patients with RA.

Conclusions

The likelihood of developing depressive disorders is greater among RA patients than among patients without RA. Symptoms of depression should be sought in patients with RA.     

An Appendectomy Increases the Risk of Rheumatoid Arthritis: A Five-Year Follow-Up Study

Many studies have reported a possible association of an appendectomy with rheumatoid arthritis (RA). However, findings of the relationship between an appendectomy and RA remain inconsistent. Furthermore, all such studies were conducted in Western societies, and relevant studies on the relationship between an appendectomy and RA in Asian countries are still lacking. In this study, we investigated the relationship between an appendectomy and the subsequent risk of RA using a population-based dataset. We retrieved data for this retrospective cohort study from the Taiwan “Longitudinal Health Insurance Database 2005”. We included 4,294 subjects who underwent an appendectomy in the study cohort and 12,882 matched subjects in the comparison cohort. We individually tracked each subject for a 5-year period from their index date to identify those who developed RA. A stratified Cox proportional hazard regression was performed to calculate the hazard ratio (HR) and its corresponding 95% confidence interval (CI) for the subsequent development of RA during the 5-year follow-up period between subjects who underwent an appendectomy and comparison subjects. Of the sampled subjects, 93 (0.54%) received a diagnosis of RA during the 5-year follow-up period: 33 from the study cohort (0.77% of subjects who underwent an appendectomy) and 60 from the comparison cohort (0.47% of comparison subjects) (p<0.001). After censoring individuals who died during the follow-up period and adjusting for subjects’ monthly income and geographic region, the HR of RA during the 5-year follow-up period was 1.61 (95% CI = 1.05~2.48) for subjects who underwent an appendectomy compared to comparison subjects. We found that among females, the adjusted HR of RA was 1.76 (95% CI = 1.04~2.96) for subjects who underwent an appendectomy compared to comparison subjects. However, there was no increased hazard of RA for males who underwent an appendectomy compared to comparison subjects. We concluded that female subjects who undergo an appendectomy have a higher risk of RA than comparison female subjects.     

Rheumatoid Arthritis and Personality: A Controlled Study

Evidence in support of claims for the existence of a special relationship between personality and rheumatoid arthritis is conflicting. In this study four groups—one of patients with early rheumatoid arthritis, one of patients with chronic rheumatoid arthritis, one of neurotic patients, and a normal control group—were compared by means of the Maudsley Personality Inventory (M.P.I.) and a neurotic trait in childhood (N.T.C.) score. Both arthritis groups had a lower M.P.I. neuroticism score than the normal control group, with greater significance in the chronic arthritis group. The neurotic group had a significantly higher neuroticism score than the other three groups. Both arthritis groups had a lower extraversion score than normal controls, again with greater significance in the chronic arthritis group. The neurotic group scored significantly less than normal controls on the extraversion scale and intermediately between the early and chronic arthritis groups. There was no significant difference between the arthritis groups and the normal control group in the N.T.C. score, but it was significantly increased in the neurotic group.These findings suggest that people with rheumatoid arthritis differ significantly in personality from normal and from neurotic people, that the differences are accentuated with chronicity in the rheumatoid process, and that the differences develop as a result of the arthritis.     

Rheumatoid Arthritis Risk Associated with Periodontitis Exposure: A Nationwide,Population-Based Cohort Study

Background

The risk of periodontitis (PD) is increased in the patient group of rheumatoid arthritis (RA). RA and PD also shared some pathological mechanism. The aim of this study is to investigate the risk of RA associated with PD exposure.

Methods and Findings

This study identified 3 mutually exclusive cohorts using the 1999–2010 Taiwanese National Health Insurance Research Database (NHIRD) to investigate the association between PD and the risk of incident RA. All patients with PD in 2000 were identified from the database of all enrollees as the PD cohort. From the representative database of 1,000,000 enrollees randomly selected in 2010 (LHID2010), individuals without any periodontal disease (PO) during 1999–2010 were selected as the non-PO cohort. Individuals who were not included in the non-PO cohort and received dental scaling (DS) no more than two times per year during 1999–2010 were selected as the DS cohort from LHID2010. Using cox proportional regression analysis, hazard ratios (HRs) with 95% confidence intervals (Cis) were calculated to quantify the association between PD exposure and RA development. In the three-group comparison using the non-PO cohort as reference, we found that the risk of RA was higher in the PD and DS cohorts (HRs, 1.89 and 1.43; 95% CIs, 1.56–2.29 and 1.09–1.87, respectively). For comparisons between two cohorts, the PD cohort had a higher risk of RA than the non-PO and DS cohorts (HRs, 1.91 and 1.35; 95% CIs, 1.57–2.30 and 1.09–1.67, respectively).

Conclusion

PD was associated with an increased risk of RA development.     

Increased Risk of Acute Pancreatitis in Patients with Rheumatoid Arthritis: A Population-Based Cohort Study

The study was conducted to determine whether patients with rheumatoid arthritis (RA) are at increased risk of acute pancreatitis compared with those without RA and to determine if the risk of acute pancreatitis varied by anti-RA drug use. We used the large population-based dataset from the National Health Insurance (NHI) program in Taiwan to conduct a retrospective cohort study. Patients newly diagnosed with RA between 2000 and 2011 were referred to as the RA group. The comparator non-RA group was matched with propensity score, using age and sex, in the same time period. We presented the incidence density by 100,000 person-years. The propensity score and all variables were analyzed in fully adjusted Cox proportional hazard regression. The cumulative incidence of acute pancreatitis was assessed by Kaplan-Meier analysis, with significance based on the log-rank test. From claims data of one million enrollees randomly sampled from the Taiwan NHI database, 29,755 adults with RA were identified and 119,020 non- RA persons were matched as a comparison group. The RA cohort had higher incidence density of acute pancreatitis (185.7 versus 119.0 per 100,000 person-years) than the non-RA cohort. The adjusted hazard ratio (HR) was 1.62 (95% CI [confidence interval] 1.43–1.83) for patients with RA to develop acute pancreatitis. Oral corticosteroid use decreased the risk of acute pancreatitis (adjusted HR 0.83, 95% CI 0.73–0.94) but without a dose-dependent effect. Current use of disease modifying anti-rheumatic drugs or tumor necrosis factor blockers did not decrease the risk of acute pancreatitis. In conclusion, patients with RA are at an elevated risk of acute pancreatitis. Use of oral corticosteroids may reduce the risk of acute pancreatitis.     

Homocysteine as a Risk Factor for Hypertension: A 2-Year Follow-Up Study

Homocysteine (Hcy) is regarded as a risk factor for hypertension, but research on the causal relationship between Hcy and hypertension is limited. In the present study, we prospectively tracked the blood pressure progression of a normotensive population with different Hcy levels over a 2-year period. The incidence of hypertension with increasing Hcy quartiles produced an approximately U-shaped curve, with significance in males. Compared with the third quartile, the risk of hypertension in the first and second quartiles was increased by 1.55 (95% confidence interval [CI] 1.154–2.081) fold and 1.501 (95% CI 1.119–2.013) fold, respectively, with the increase being more significant in males. In conclusion, Hcy is related to hypertension incidence with the results approximating an U-shaped curve. Low Hcy levels might also increase the risk of hypertension.     

Increased Level of Lipid Peroxidation Products as a Risk Factor of Death in a Prospective Study

The peroxidation-based theory concerning the pathogenesis of atherosclerosis suggests that this disease is a result of the activation of free-radical oxidation and the accumulation of lipid peroxidation (LP) products in the body. This theory needs to be verified by prospective observation data to correlate the latter phenomenon with the increased prevalence of morbidity and mortality among patients with this and related diseases. The authors analyzed the mortality of 35- to 60-year-old males (n = 339) in a ten-year period depending on the initial level of LP fluorescent products (LPFP). Cardiovascular diseases were the main fatal factor in the examined group (47.4%). Mean LPFP levels were initially higher in the subjects who died before the end of the study than in those who survived. Using Coxe's proportional risk model, it was demonstrated that an increased LPFP level is an independent mortality risk factor. An increase in the LPFP level above 15 mmol of fluorene equivalents per mol cholesterol of apo-B-lipoproteins was associated with a nearly 2.4-fold increase in the mortality risk, and its significance was comparable with that of arterial hypertension. The prospective study showed that an increased level of LP products in blood plasma is a major mortality risk factor, being no less strong than the first order (etiological) factors.     

Risk of Rheumatoid Arthritis in Patients with Type 2 Diabetes: A Nationwide Population-Based Case-Control Study

Objective

Type 2 diabetes is associated with chronic, low-grade inflammation and could potentially trigger the progression of other, more prominent inflammatory diseases such as rheumatoid arthritis (RA). Therefore, we aimed to investigate the risk of incident RA in Taiwanese patients with type 2 diabetes using a population-based health claims database.

Methods

This nationwide, population-based, case-control study used administrative data to identify 1,416 patients with RA (age ≥20 years) as cases and 7,080 controls that were frequency-matched for sex, 10-year age group, and year of catastrophic illness certificate application date (index year). All subjects were retrospectively traced back, up to 13 years prior to the index year, for their first diagnosis of type 2 diabetes. Logistic regression analysis was conducted to quantify the association between incident RA and type 2 diabetes.

Results

The odds of developing RA were significantly higher in female (odds ratio [OR] 1.46, 95% confidence interval [95% CI] 1.24–1.72) but not in male (OR 1.00, 95% CI 0.72–1.37) patients who had previously diagnosed with type 2 diabetes. Subgroup analysis indicated that the odds of developing RA were more prominent in younger females (20 to 44 years of age) with type 2 diabetes. In addition, the odds of developing RA in female patients with type 2 diabetes were higher in those with a shorter time interval between the diagnosis of type 2 diabetes and RA.

Conclusions

This large nationwide, population-based, case-control study showed an elevated risk of RA in female Taiwanese patients with type 2 diabetes. Our findings were consistent with the hypothesis that chronic low-grade inflammation in type 2 diabetes may elicit the development of RA in genetically susceptible individuals.     

Depressive Symptoms as a Novel Risk Factor for Recurrent Venous Thromboembolism: A Longitudinal Observational Study in Patients Referred for Thrombophilia Investigation

BackgroundIncreasing evidence suggests that psychosocial factors, including depression predict incident venous thromboembolism (VTE) against a background of genetic and acquired risk factors. The role of psychosocial factors for the risk of recurrent VTE has not previously been examined. We hypothesized that depressive symptoms in patients with prior VTE are associated with an increased risk of recurrent VTE.MethodsIn this longitudinal observational study, we investigated 271 consecutive patients, aged 18 years or older, referred for thrombophilia investigation with an objectively diagnosed episode of VTE. Patients completed the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). During the observation period, they were contacted by phone and information on recurrent VTE, anticoagulation therapy, and thromboprophylaxis in risk situations was collected.ResultsClinically relevant depressive symptoms (HADS-D score ≥8) were present in 10% of patients. During a median observation period of 13 months (range 5-48), 27 (10%) patients experienced recurrent VTE. After controlling for sociodemographic and clinical factors, a 3-point increase on the HADS-D score was associated with a 44% greater risk of recurrent VTE (OR 1.44, 95% CI 1.02, 2.06). Compared to patients with lower levels of depressive symptoms (HADS-D score: range 0-2), those with higher levels (HADS-D score: range 3-16) had a 4.1-times greater risk of recurrent VTE (OR 4.07, 95% CI 1.55, 10.66).ConclusionsThe findings suggest that depressive symptoms might contribute to an increased risk of recurrent VTE independent of other prognostic factors. An increased risk might already be present at subclinical levels of depressive symptoms.     

Alcohol as a Risk Factor for Cancer Burden: A Review

Alcohol is eliminated from the body by various metabolic mechanisms. The primary enzymes in such mechanism involved are alcohol dehydrogenase, aldehyde dehydrogenase, cytochrome P450 2E1, and catalase. Variations in the genes for these enzymes have been found to influence alcohol consumption. The consequences of alcohol metabolism include oxygen deficits (i.e., hypoxia) in the liver, resulting in the formation of harmful compounds (i.e., adducts) and highly reactive oxygen-containing molecules (i.e., reactive oxygen species) that can damage cell components. Approximately, worldwide 3.6 % of cancers derive from chronic alcohol drinking, including those of the upper aerodigestive tract, the liver, the colorectum and the breast. Although the mechanisms for alcohol-associated carcinogenesis are not completely understood, recent findings have focused on acetaldehyde, the first and most toxic ethanol metabolite, as a cancer-causing agent. Alcohol-related carcinogenesis may aggravate due to other factors such as smoking and being triggered by genetic susceptibility. Besides, the role of genetic polymorphisms of the alcohol-metabolizing enzymes could not be ruled out.     

The Risk Factors for Developing Clustered Vertebral Compression Fractures: A Single-Center Study

ObjectiveVertebral compression fractures (VCFs) are common among elderly individuals, but clustered VCFs (C-VCFs) are rare and more severe. The risk factors for C-VCFs remain unclear. Thus, we investigated the clinical characteristics of C-VCFs to identify the imminent fracture risk and improve the treatment for such patients.MethodsWe reviewed the records of patients with VCF at a single medical center between January 2011 and September 2020. Patients who had 4 or more VCFs within 1 year were categorized into the C-VCF group, and the remaining patients were paired into the control group at a ratio of 2:1. We collected demographic, clinical, laboratory, and radiologic information regarding these patients. Univariate analyses, stratified analyses, and multivariate logistic regression were performed to identify the risk factors for C-VCFs.ResultsA total of 156 patients were enrolled, of whom 52 were patients with C-VCF. Patients with C-VCF had more severe fractures and pain, with fractures occurring at uncommon sites of the spine. The independent risk factors for C-VCFs included glucocorticoid (GC) treatment (P < .001; hazard ratio [HR], 12.7), recent fracture history (P = .021; HR, 5.5), and lower trabecular bone score (TBS) (P = .044; HR, 1.6). TBS and bone mineral density had greater predictive values in patients without GC treatment (P < .001). Sex, age, and bone turnover biomarkers were not independent risk factors for C-VCFs.ConclusionC-VCFs are rare adverse consequences of severe osteoporosis, for which GC treatment, recent fracture history, and lower TBS are unique risk factors that are valuable for the early identification and prevention of C-VCFs.     

Cholesterol as a Risk Factor for Subarachnoid Hemorrhage: A Systematic Review

BackgroundThe role played by total cholesterol (TC) in risk for subarachnoid hemorrhage (SAH) is unclear because studies report both high and low TC each as a risk factor. We performed a systematic review to clarify associations between lipid profile and SAH.MethodsOur literature search comprised Pubmed, Scopus, and Cochrane Library databases with no language, publication year, or study type limitations. The Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) checklist guided our reporting. Data forms adapted from the Critical Appraisal Skills Program (CASP), and Cochrane Collaboration guidelines provided a platform for risk-of-bias evaluation. We used a random effects model to calculate pooled estimates and assessed heterogeneity with I²-statistics.ResultsOf the final 21 studies reviewed, 12 were prospective and 9 retrospective. All studies assessed TC, four assessed HDL, and none LDL in risk for SAH. Heterogeneity among all, retrospective, and Asian studies was high (I² = 79.5%, I² = 89.0%, and I² = 84.3%) and considerable in prospective (I² = 46.0%). We therefore focused on qualitative analysis and found that only two studies had a low risk of bias. According to these studies high TC increases risk for SAH in men, whereas the role of HDL remained unclear.ConclusionThe low-risk-of-bias studies suggest that elevated TC levels elevate risk for SAH in men. Due to the high prevalence of hypercholesterolemia, population attributable risk (PAR) of hypercholesterolemia may exceed the PARs of smoking and hypertension in men. Apart from diabetes and obesity, the risk-factor profile of SAH seems to resemble that of other cerebrovascular diseases, at least in men.     

Immunochip Identifies Novel,and Replicates Known,Genetic Risk Loci for Rheumatoid Arthritis in Black South Africans

The aim of this study was to identify genetic variants associated with rheumatoid arthritis (RA) risk in black South Africans. Black South African RA patients (n = 263) were compared with healthy controls (n = 374). Genotyping was performed using the Immunochip, and four-digit high-resolution human leukocyte antigen (HLA) typing was performed by DNA sequencing of exon 2. Standard quality control measures were implemented on the data. The strongest associations were in the intergenic region between the HLA-DRB1 and HLA-DQA1 loci. After conditioning on HLA-DRB1 alleles, the effect in the rest of the extended major histocompatibility (MHC) diminished. Non-HLA single nucleotide polymorphisms (SNPs) in the intergenic regions LOC389203|RBPJ, LOC100131131|IL1R1, KIAA1919|REV3L, LOC643749|TRAF3IP2, and SNPs in the intron and untranslated regions (UTR) of IRF1 and the intronic region of ICOS and KIAA1542 showed association with RA (p < 5 × 10⁻⁵). Of the SNPs previously associated with RA in Caucasians, one SNP, rs874040, locating to the intergenic region LOC389203|RBPJ was replicated in this study. None of the variants in the PTPN22 gene was significantly associated. The seropositive subgroups showed similar results to the overall cohort. The effects observed across the HLA region are most likely due to HLA-DRB1, and secondary effects in the extended MHC cannot be detected. Seven non-HLA loci are associated with RA in black South Africans. Similar to Caucasians, the intergenic region between LOC38920 and RBPJ is associated with RA in this population. The strong association of the R620W variant of the PTPN22 gene with RA in Caucasians was not replicated since this variant was monomorphic in our study, but other SNP variants of the PTPN22 gene were also not associated with RA in black South Africans, suggesting that this locus does not play a major role in RA in this population.     

Association of CD247 Polymorphisms with Rheumatoid Arthritis: A Replication Study and a Meta-Analysis

Given the role of CD247 in the response of the T cells, its entailment in autoimmune diseases and in order to better clarify the role of this gene in RA susceptibility, we aimed to analyze CD247 gene variants previously associated with other autoimmune diseases (rs1052237, rs2056626 and rs864537) in a large independent European Caucasian population. However, no evidence of association was found for the analyzed CD247 single-nucleotide polymorphisms (SNPs) with RA and with the presence/absence of anti-cyclic citrullinated polypeptide. We performed a meta-analysis including previously published GWAS data from the rs864537 variant, revealing an overall genome-wide significant association between this CD247 SNP and RA with anti-CCP (OR = 0.90, CI 95% = 0.87–0.93, P_overall = 2.1×10⁻¹⁰). Our results show for first time a GWAS-level association between this CD247 polymorphism and RA risk.     

Fears and Beliefs in Rheumatoid Arthritis and Spondyloarthritis: A Qualitative Study

ObjectivesTo explore beliefs and apprehensions about disease and its treatment in patients with rheumatoid arthritis and spondyloarthritis.Methods25 patients with rheumatoid arthritis and 25 with spondyloarthritis participated in semi-structured interviews about their disease and its treatment. The interviews were performed by trained interviewers in participants'' homes. The interviews were recorded and the main themes identified by content analysis.ResultsPatients differentiated between the underlying cause of the disease, which was most frequently identified as a hereditary or individual predisposition. In patients with rheumatoid arthritis, the most frequently cited triggering factor for disease onset was a psychological factor or life-event, whereas patients with spondyloarthritis tended to focus more on an intrinsic vulnerability to disease. Stress and overexertion were considered important triggering factors for exacerbations, and relaxation techniques were frequently cited strategies to manage exacerbations. The unpredictability of the disease course was a common source of anxiety. Beliefs about the disease and apprehensions about the future tended to evolve over the course of the disease, as did treatment expectations.ConclusionsPatients with rheumatoid arthritis and spondyloarthritis hold a core set of beliefs and apprehensions that reflect their level of information about their disease and are not necessarily appropriate. The physician can initiate discussion of these beliefs in order to dispel misconceptions, align treatment expectations, provide reassurance to the patient and readjust disease management. Such a dialogue would help improve standards of care in these chronic and incapacitating diseases.     

The Risk of Metabolic Syndrome in Patients with Rheumatoid Arthritis: A Meta-Analysis of Observational Studies

Background

Observational studies suggest an association between the incidence of rheumatoid arthritis (RA) and the prevalence of metabolic syndrome (MetS). However, the relationship between RA and MetS is controversial and research in this area is currently lacking.

Objective

The aim of this study was to assess whether the prevalence of MetS was higher in a group of RA patients compared to subjects without RA.

Design

A PubMed database search was conducted during April 2013 to identify observational studies of RA and risk of MetS. Reference lists of retrieved articles were also reviewed. Two authors independently extracted information on the study design, the characteristics of the study participants, exposure and outcome assessments, and the method used to control for potential confounding factors. A random-effects model was used for the risk estimates.

Results

Our meta-analysis of four cross-sectional controlled studies plus eight case-control studies involving a total of 2283 cases and 4403 controls identified a significant association between RA and risk of MetS, with an overall OR of 1.24 (95% CI, 1.03-1.50).

Conclusion

This meta-analysis provides further evidence supporting patients with RA have a higher prevalence of MetS than subjects without RA. In addition, the geographic region of the population and the criteria used for MetS diagnosis could influence the association. However, these observations would need to be evaluated using prospective, randomized studies.