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Benzodiazepine use is associated with delirium, and guidelines recommend avoiding them in older and critically ill patients. Their perioperative use remains common because of perceived benefits.We searched CENTRAL, MEDLINE, CINAHL, PsycInfo, and Web of Science from inception to June 2021. Pairs of reviewers identified randomised controlled trials and prospective observational studies comparing perioperative use of benzodiazepines with other agents or placebo in patients undergoing surgery. Two reviewers independently abstracted data, which we combined using a random-effects model. Our primary outcomes were delirium, intraoperative awareness, and mortality.We included 34 randomised controlled trials (n=4354) and nine observational studies (n=3309). Observational studies were considered separately. Perioperative benzodiazepines did not increase the risk of delirium (n=1352; risk ratio [RR] 1.43; 95% confidence interval [CI]: 0.9-2.27; IIn this systematic review and meta-analysis, perioperative benzodiazepine use did not increase postoperative delirium and decreased intraoperative awareness. Previously observed relationships of benzodiazepine use with delirium could be explained by comparisons with dexmedetomidine.PROSPERO CRD42019128144.

Context: The CanMEDS framework promotes the development of competencies required to be an effective physician. However, it is still not well understood how to apply such frameworks to CPD contexts, particularly with respect to intrinsic competencies. Objective: This study explores whether physician narratives around challenging cases would provide information regarding learning needs that could help guide the development of CPD activities for intrinsic CanMEDS competencies. Methods: We surveyed medical and surgical specialists from Southern Ontario using an online survey. To assess perceived needs, participants were asked, ‘Describe three CPD topic you would like to learn about in the next 12 months’. To identify learning needs that may have arisen from problems encountered in practice, participants were asked, ‘Describe three challenging situations encountered in the past 12 months.’ Responses to the two open-ended questions were analyzed using thematic content analysis. Results: Responses were received from 411 physicians, resulting in 226 intrinsic CanMEDS codes for perceived learning needs and 210 intrinsic codes for challenges encountered in practices. Discrepancies in the frequency of intrinsic roles were observed between the two questions. Specifically, Leader (28%), Scholar (43%), and Professional (16%) roles were frequently described perceived learning needs, as opposed to challenges in practice (Leader: 3%; Scholar: 2%; and Professional: 8%. Conversely, Communicator 39%, Health Advocate 39%, and to a lesser extent Collaborator 11%) roles were frequently described in narratives surrounding challenges in practice, but appeared in

Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P = 0.02), and less likely to be older (OR, 0.96; P = 0.002), single (OR, 0.34; P = 0.006), divorced (OR, 0.53; P = 0.03), immigrants (OR, 0.38; P = 0.049), or from the lowest income quintile (OR, 0.44; P = 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through targeted interventions in underrepresented populations. Liver Transpl 21:897-903, 2015. © 2015 AASLD.

Background: The optimal antithrombotic regimen for patients with coexistent atrial fibrillation (AF) and coronary artery disease (CAD) requiring percutaneous coronary intervention (PCI) remains controversial.Methods: We performed a chart review of 2,645 consecutive patients with non-ST elevation or ST elevation myocardial infarction at a regional cardiac centre, to examine the clinical characteristics and discharge antithrombotic medications of patients with coexistent AF (known or new onset AF with CHADS2 ≥1), treated with PCI.Results: Among 2,645 patients, 94 eligible patients were analyzed and 30 (32%) were prescribed triple therapy (TT) at hospital discharge. CHADS2 score was the major predictor of the decision to prescribe TT (P =0.002).Conclusion: Approximately one-third of the patients with AF undergoing PCI were prescribed TT at hospital discharge. Clinicians are generally following national guidelines and internationally-developed consensus statements, and focus on stroke risk despite the risks of bleeding and insufficient evidence supporting the benefits of TT. RésuméContexte : Le régime optimal antithrombotique pour les patients atteints à la fois de fibrillation atriale (FA) et d’une coronaropathie nécessitant une angioplastie coronarienne percutanée (ACP) demeure controversé.Méthodologie: Dans un centre régional de cardiologie, nous avons examiné les dossiers médicaux de 2645 patients ayant subi un infarctus du myocarde avec ou sans sus‑décalage du segment ST. Le but consistait à analyser les caractéristiques cliniques des patients présentant une FA concomitante (ancienne ou nouvelle, avec un indice CHADS2 ≥ 1) traitée par ACP, et les médicaments antithrombotiques prescrits au moment de leur sortie de l’hôpital.Résultats: Parmi les 2645 dossiers, 94 patients admissibles ont été analysés. Trente (32 %) s’étaient vus prescrire une trithérapie (TT) à leur sortie de l’hôpital. L’indice CHADS2 était le principal indicateur prévisionnel pris en compte dans la décision de prescrire la TT (P = 0,002).Conclusion : Environ un tiers des patients atteints de FA et ayant subi une ACP se sont vus prescrire une TT à leur sortie de l’hôpital. En général, les cliniciens suivent les directives nationales et les protocoles consensuels élaborés à l’international et se concentrent sur le risque d’ictus, malgré les risques de saignements et le manque de données probantes soutenant les avantages d’une TT.BACKGROUNDDual antiplatelet therapy (DAPT) including Aspirin and a P2Y12 receptor antagonist is recommended for patients who undergo percutaneous coronary intervention (PCI) with stent implantation.1,2 DAPT is superior to oral anticoagulants (OAC) in preventing stent thrombosis, 3while OAC is superior to DAPT in reducing stroke in patients with atrial fibrillation (AF).4,5 It is estimated that 5–8% of patients sustaining an acute coronary syndrome (ACS) have concomitant AF.6,7 The optimal antithrombotic regimen for patients with coexistent AF and coronary artery disease (CAD) requiring PCI remains controversial. In patients with AF and CHADS2 stroke risk score ≥1, consensus statements suggest that triple therapy (TT), defined as a combination of DAPT + OAC, be utilized in patients undergoing PCI with ACS.8,9 However, there is data indicating no improved efficacy of treatment with TT compared with DAPT alone, while exposing patients to increased bleeding risk.7,10,11 Major bleeding has been proven to be independently associated with death in patients following an ACS.12 Therefore, balancing the thromboembolic and bleeding risk is critical in patients with a recent ACS.Large randomized trials have indicated that compared with warfarin, novel oral anticoagulants (NOAC’s) are at least as effective as, and are associated with reduced rates of major, fatal and intracranial bleeding in patients with non-valvular AF.13 Due to the favourable safety profile, NOACs are being evaluated against warfarin in patients with AF undergoing PCI. Three of these trials are ongoing (RE-DUAL PCI, AUGUSTUS, ENTRUST-AF-PCI),14–16 and the fourth is the recently published PIONEER AF-PCI trial, which showed that reduced-dose rivaroxaban combined with clopidogrel lowered the risk of bleeding compared with TT with warfarin.17Despite the emergence of these recent data, the highest risk patients remain excluded from large randomized trials, and thus sound clinical judgment will remain the cornerstone in caring for these patients. In the current study, we aim to describe the local practice patterns of clinicians making treatment decisions for patients with new or existing AF, who present with an ACS and undergo PCI.METHODSA retrospective and prospective chart review was performed on 2,645 consecutive patients presenting with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial elevation (NSTEMI) to 3 academic hospitals affiliated with McMaster University and 8 community hospitals located in Local Health Integrated Network (LHIN) 4, Ontario, Canada from January to December 2014. Of those, 1,458 patients had undergone PCI with stent implantation; and, 124 patients were identified to have concomitant AF (Figure 1). Inclusion criteria for our study were: admission to hospital for either STEMI or NSTEMI, known or new onset AF with CHADS2 ≥ 1, coronary angiography demonstrating at least one epicardial coronary artery with a ≥70% stenosis, and successful PCI with stent implantation. Patients who expired before discharge were excluded from the analysis. Clinical and demographic characteristics of patients were summarized. DAPT and TT groups were identified by reviewing medication records from discharge summaries or copies of discharge prescriptions. DAPT was defined as Aspirin plus clopidogrel (75 mg once daily) or ticagrelor (90 mg twice daily), while TT was defined as DAPT plus an OAC; including either warfarin or novel oral anticoagulants (NOAC). We analyzed the CHADS2 and ATRIA (Anticoagulation and Risk factors in Atrial fibrillation) scores according to treatment groups.18,19 Statistical analysis was performed using SAS/STAT version 9.3 (SAS Institute Inc., Cary, NC). Categorical data was compared using Chi-square testing. Continuous data comparison was performed applying the Wilcoxon test and Cochran-Armitage test for trends. A binary logistic regression model was developed to identify the clinical predictors of discharge groups based on their CHADS 2 and ATRIA scores (Figure 2 and Figure 3). The cut-off for statistical significance was a P-value of

Background: Impaired marital adjustment has been introduced as one major complication of PTSD. There are controversial results about the role of Cognitive Behavioral Couple' s Therapy (CBCT) on improvement of marital adjustment of PTSD veterans; the efficacy of CBCT on marital adjustment improvement is questioned in some studies and also there are no similar researches about the affect of CBCT on marital adjustment, conducted among Middle Eastern PTSD veterans. These factors motivated us to perform and evaluate our CBCT protocol among Iranian combat veterans. Methods: we enrolled 60 PTSD veterans with low degrees of marital adjustment. They were randomly distributed into intervention and control groups. Both groups have been evaluated for marital adjustment by means of ENRICH scale before and after intervention and the results were analyzed by MANOVA test. Results: The analysis was based on difference of T2 and T1 (T2-T1) where the mean of T2-T1 was -2.63 for control group and 44.9 for intervention group, sum of squares 69552.7, f=95.4 and sig. �000.1. Conclusion: this shows that the prevalence of marital maladjustment is high among PTSD veterans (43%) and the efficacy of CBCT was significant both for veterans themselves and their spouses.