Identifying Risk Factors for Cardiovascular Events Among Active-Duty Service Members and Veterans Prescribed Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).

Background: Oral NSAIDs are widely used analgesic medications for the treatment of musculoskeletal and inflammatory conditions. NSAIDs are associated with adverse effects that arise from COX enzyme inhibition including cardiovascular events. The combined role of patient and prescription factors associated with NSAID use on cardiovascular risk is not well characterized. Objective: The purpose of this study is to identify the risk factors with cardiovascular events among NSAID users. Methods: This study is a retrospective, nested case-control study, within the DAVINCI database, among active-duty service members and veterans with at least one NSAID pharmacy claim between fiscal year (FY) 2015-FY2020. Inclusion criteria individuals ≥18 years of age received a prescription NSAID for ≥7-day supply and a duration ≥1 month overall. Cases experienced nonfatal myocardial infarction, nonfatal stroke, or new onset heart failure. Ten controls were selected per case. Risk factors were identified through logistic regression modeling. Results: The risk factors with strongest association to the primary outcome included age starting at 45 up to 75 and older, the first 90 days of NSAID exposure, cerebrovascular disease, cardiomyopathy, and history of myocardial infarction. Cox-selectivity and dose did not appear to be clinically significant in their association with cardiovascular events. Conclusion: The results of this study indicate that age, initial NSAID exposure, and comorbidities are more predictive than NSAID-specific factors such as COX-selectivity and dose. The results provide the framework for development of a risk score to improve prediction of NSAID-associated cardiovascular events.

A review of the safety of buprenorphine in special populations.

Rates of opioid misuse and opioid use disorder have been increasing in recent years. Buprenorphine has emerged as an appealing medication for its use not only as treatment for opioid use disorder, but also as an opioid for chronic pain that has a ceiling effect on risks associated with opioid therapy. As other opioid prescribing decreases, buprenorphine prescribing continues to increase. As a result, it is imperative to understand the safety and efficacy of its use in special populations. This review article will explore the safety and efficacy of buprenorphine when used in subjects with hepatic and renal impairment, the elderly, and pregnant women. While manufacturer labeling for buprenorphine products may caution against their use in these populations, further examination of available data indicates that buprenorphine can be used safely and effectively for both chronic pain and/or opioid use disorder in all four of these populations.

The Management of Substance Use Disorders: Synopsis of the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). This synopsis summarizes key recommendations. METHODS: In March 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2015 VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 35 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis presents the recommendations that were believed to be the most clinically impactful. RECOMMENDATIONS: The scope of the CPG is broad; however, this synopsis focuses on key recommendations for the management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.

Frailty and stroke thrombectomy outcomes-an observational cohort study.

INTRODUCTION: Mechanical thrombectomy (MT) can improve outcomes following ischaemic stroke. Patient selection for MT is predominantly based on physiological and imaging parameters. We assessed whether people living with pre-stroke frailty had differing outcomes following MT. METHODS: We included consecutive patients undergoing MT at a UK comprehensive stroke centre. We calculated a cumulative deficits frailty index to identify pre-stroke frailty in those patients presenting directly to the centre. Frailty was defined as an index score ≥ 0.24. We assessed univariable and multivariable association between pre-stroke frailty and stroke outcomes. Our primary outcomes were modified Rankin Scale (mRS) and mortality at 90 days. RESULTS: Of 175 patients who underwent MT (2014-2018), we identified frailty in 49 (28%). Frail and non-frail patients had similar rates of thrombolysis administration, successful recanalization and onset to recanalization times. Those with pre-stroke frailty had higher 24 hour National Institutes of Health Stroke Scale (12(IQR: 8-17) versus 3(IQR: 2-13); P = 0.001); were less likely to be independent (mRS 0-2: 18% versus 61%; P < 0.001) and more likely to die (47% versus 14%; P < 0.001) within 90 days. Adjusting for age, baseline NIHSS and thrombolysis, frailty remained a strong, independent predictor of poor clinical outcome at 90 days (Death OR: 3.12 (95% CI: 1.32-7.4); dependency OR: 3.04 (95%CI: 1.10-8.44). Age was no longer a predictor of outcome when adjusted for frailty. CONCLUSION: Pre-stroke frailty is prevalent in real-world patients eligible for MT and is an important predictor of poor outcomes. Routine assessment of pre-stroke frailty could help decision-making around patient selection for MT.

Pain Management and Opioid Therapy: Persistent Knowledge Gaps Among Primary Care Providers.

INTRODUCTION: Given the opioid epidemic in the US, it is vital that clinicians who prescribe opioids for pain management to do so in an evidence-based manner, eg considering all pharmacologic and non-pharmacologic options, assessing risk of opioid use disorder prior to initiating opioids. Continuing education regarding the evidence-based prescribing of opioids is now required for US healthcare providers who prescribe opioids. A "blueprint" of the content to be included in continuing education programs was developed by the US Food and Drug Administration and updated in 2018. METHODS: To understand the baseline knowledge and confidence of healthcare professionals in prescribing opioids for pain management, we posed 27 unique knowledge-based questions and 1 confidence question to clinician participants before or during 2 continuing educational programs that were based respectively on the 2016 and 2018 FDA Risk Evaluation and Mitigation Strategy (REMS) educational blueprints for pain management. RESULTS: Overall, 5571 clinicians completed these programs, including 1925 physicians (1516 [79%] identifying as primary care), 1181 physician assistants, 737 advanced practice nurses, 719 nurses, and 479 pharmacists. Responses to pretest questions in both programs indicated profound and persistent gaps in knowledge, particularly in definitions and mechanisms of pain, general principles of pharmacologic analgesic therapy, and specific aspects of opioid analgesic therapy and addiction. Participants in both programs also expressed limited confidence in their abilities to incorporate patient engagement techniques into pain management or develop a treatment plan for a patient with chronic pain. DISCUSSION: These data support an ongoing need for comprehensive clinician-based education as outlined in the FDA REMS educational blueprint, especially given recent data of escalating overdose deaths during the COVID-19 pandemic.

COVID-19 in a rural health system in New York - case series and an approach to management.

INTRODUCTION: Many rural hospitals and health systems in the USA lack sufficient resources to treat COVID-19. St Lawrence Health (SLH) developed a system for managing inpatient COVID-19 hospital admissions in St Lawrence County, an underserved rural county that is the largest county in New York State. METHODS: SLH used a hub-and-spoke system to route COVID-19 patients to its flagship hospital. It further assembled a small clinical team to manage admitted COVID-19 patients and to stay abreast of a quickly changing body of literature and standard of care. A review of clinical data was completed for patients who were treated by SLH's inpatient COVID-19 treatment team between 20 March and 22 May 2020. RESULTS: Twenty COVID-19 patients were identified. Sixteen patients (80%) met National Institutes of Health criteria for severe or critical disease. One patient died. No patients were transferred to other hospitals. CONCLUSION: During the first 2 months of the pandemic, the authors were able to manage hospitalized COVID-19 patients in their rural community. Development of similar treatment models in other rural areas should be considered.

Loss of Meaning at Work Associated with Burnout Risk in Academic Medicine.

OBJECTIVES: Meaning at work has been proposed as one of the key drivers of professional burnout in healthcare, but few studies have simultaneously measured this relation. METHODS: In this cross-sectional analysis of 1637 individuals at the University of Arkansas for Medical Sciences, burnout was measured using the Copenhagen Burnout Inventory work-related subscale. RESULTS: Meaningful work was measured using items adapted from the Work as Meaning Inventory. The prevalence of work-related burnout increased with each level of diminished meaning at work. From the highest ("always") to the lowest ("never") level of meaning at work, the prevalence of burnout was: 13, 26, 57, 84, and 94%, respectively. CONCLUSIONS: Work-related burnout was inversely proportional to reported meaning at work in an academic medical center.

Psychometric Properties of the Copenhagen Burnout Inventory in an Academic Healthcare Institution Sample in the U.S.

The Copenhagen Burnout Inventory (CBI) has demonstrated good psychometric properties among respondents in many different countries, but minimal research exists using the CBI in a U.S.-based sample. The current study represents a secondary analysis of existing CBI data from 1,679 academic health center employees at one mid-size teaching hospital in the southeastern region of the U.S. Analyses assessed CBI scale reliability, confirmatory factorial validity, discriminant validity against a measure of meaningful work, and test invariance for professional role sub-groups (physicians, nurses/physician assistants, and other hospital staff), gender groups, and different age groups. Results provided evidence for good reliability and discriminant validity as well as construct validity supporting the CBI proposed three-factor structure. Configural and metric variance equivalence were demonstrated across the range of employee types, and across age and gender groups. Scalar invariance equivalence was not established, suggesting further research may be needed to support group mean comparisons using the CBI.

Empowering Medical Students to Respond to Discriminatory Comments from Patients: A Just-in-Time Training Method.

This article was migrated. The article was marked as recommended. Physicians in training may experience harassment and discrimination from supervisors, consultants, colleagues, or patients and families. Instances of discrimination towards students may impact students' self-esteem, self-efficacy, and ultimately performance. In this particular time, many institutions are looking to enhance their curriculum regarding bias. More tools are needed to help students feel empowered to respond professionally when they encounter challenging situations. This study was designed to assess the impact of a training intervention in addressing biased patient statements. The training was strategically placed prior to clinical interactions. The authors' intention was to present discriminatory statements by patients as one of the many difficult clinical situations that students are being trained to navigate. The authors developed a clinical rubric for decision-making in flowchart style to mimic the decision trees used in diagnostic or treatment decisions. They then created a workshop to help learners use the flowsheet. The workshop was delivered to third-year medical students as part of "Junior Bootcamp," a day-long session of events to orient students to the clinical experiences of the M3 year. The workshop was delivered in the summer of 2019. Respondents indicated that they were more likely to be able to appropriately respond to discriminatory comments after completing the workshop. They also felt that they were more likely to be able to engage in respectful dialogue with a patient and to debrief with a faculty member. Fewer participants felt that they were likely to use the flowchart. Findings indicate that the workshop was useful to participants. It may be especially useful to educators dealing with the COVID pandemic because it is scalable and easily delivered remotely. Further studies are needed to determine if introducing this topic in the clinical years of medical school leads to improved skill in addressing instances of bias that come from patients and families.

Nonsteroidal Antiinflammatory Drugs for Acute and Chronic Pain.

Understanding nonsteroidal antiinflammatory drug (NSAID) use and impact on common rheumatic and arthritic conditions is critical to reconciling their appropriate use with their potentially serious adverse effects. NSAIDs have a profound impact on the treatment of connective tissue disorders because of their ability to address the underlying cause with specific benefits of decreasing stiffness and inflammation, and improving mobility. NSAID use is twice as common as opioid use, and inappropriate use of NSAIDs is widespread. NSAID use should be monitored and the impact understood to mitigate the risks. NSAID discontinuation should be evidence based and individualized to specific requirements.

Using Didactics and Simulation to Enhance Comfort, Knowledge, and Skills of Nonsurgical Trainees Caring for Patients With Tracheostomy and Laryngectomy.

INTRODUCTION: Management of tracheostomy and laryngectomy is an important skill for physicians who often care for patients with multiple, comorbid, chronic medical conditions. There is little published literature on training for tracheostomy and laryngectomy care during nonsurgical specialty residencies. This project was designed to assess and improve comfort with, knowledge of, proficiency in tracheostomy and laryngectomy care. METHODS: This prospective observational study comprised 122 physician trainees from internal medicine, emergency medicine, and anesthesia training programs at the University of Arkansas for Medical Sciences participating in a simulation-based curriculum from April 2016 to December 2016. The curriculum included didactic session, hands-on experience performing a tracheostomy change, and practicing emergency scenarios on interactive, high-fidelity simulation mannequins. Preintervention and postintervention assessments of self-perceived comfort, objective knowledge, and tracheostomy change proficiency were performed and results compared. RESULTS: Self-perceived comfort improved from a mean Likert score from 2.12 to 4.43 (P = 0.009). Knowledge mean scores improved from 57% to 82% (P < 0.001) on multiple-choice testing. Tracheostomy change proficiency mean scores improved from 41% to 84% (P < 0.001) of proficiencies correctly performed. Six-month follow-up assessment of comfort and knowledge showed statistically significant retention of comfort (P = 0.002) and knowledge (P = 0.026). CONCLUSIONS: Comprehensive tracheostomy and laryngectomy education, which combines enhancement of knowledge with simulation of both routine and emergent aspects of care, is an effective strategy in improving confidence with, knowledge of, proficiency in tracheostomy and laryngectomy care. Retention of confidence and knowledge was demonstrated 6 months later.

Common elements in opioid use disorder guidelines for buprenorphine prescribing.

OBJECTIVES: This study sought to formulate a consolidation of guidelines representing best practices related to office-based opioid treatment (OBOT) of opioid use disorder (OUD) using buprenorphine. It also demonstrates how a set of evidence-based guidelines may be linked with claims data to leverage analytic techniques that drive cost-effective, positive health outcomes. STUDY DESIGN: Literature review of US and international guidelines for OBOT using buprenorphine for OUD. METHODS: The study conducted a review of currently available US and several international guidelines from 2009 to 2018 published on OUD and the use of buprenorphine in OBOT. Guidelines were consolidated based on common elements. The process of correlating common elements with available commercial and state Medicaid claims data is described, including which elements are amenable to analysis along with relative complexity. RESULTS: Seven guidelines met inclusion criteria and are presented as 3 tables, organized by clinical themes and phase of care related to OBOT use of buprenorphine for OUD. Themes included establishing care, monitoring treatment stability and engagement, and nonpharmacologic treatment to improve outcomes. Areas of agreement and divergence between guidelines are highlighted. Specific components are identified as they relate to metrics of interest to public and private payers. CONCLUSIONS: Among US and international guidelines for treatment of OUD, common themes are readily identified and may indicate agreement in regard to interventions. Linking pharmacy and medical billing claims data to evidence-supported best practices provides public and private payers the ability to track individual patients, facilitate high-quality care, and monitor outcomes.

Differences in burnout prevalence between clinical professionals and biomedical scientists in an academic medical centre: a cross-sectional survey.

OBJECTIVE: To determine the prevalence and associated factors for personal, work-related and patient/client-related burnout in clinical professionals and biomedical scientists in academic medicine. DESIGN: Prevalence survey using the Copenhagen Burnout Inventory. SETTING: Mid-size academic health centre. PARTICIPANTS: Clinical providers (n=6489) and biomedical scientists (n=248) were invited to complete the survey. 1646 completed responses (response rate 24.4%) were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence estimates and adjusted ORs (AOR) were stratified for gender, age and professional category. RESULTS: Type of burnout varies across professional categories, with significant differences between clinicians and scientists. The prevalence of personal burnout was 52.7% (95%CI 50% to 55%), work-related burnout 47.5% (95%CI 45% to 49%) and patient/client-related burnout 20.3% (95%CI 18% to 22%). The prevalence of personal and work-related burnout was higher among women, while those aged 20-30 had a higher prevalence of all three burnout categories. Overall, clinical professionals had higher personal and work-related burnout, while biomedical scientists had higher client-related burnout. Accounting for the effects of gender and age, a significantly higher risk for personal burnout was found for physicians (AOR 1.64; 95%CI 1.3 to 2.1) and nurses (AOR 1.5; 95%CI 1.03 to 2.2). Significantly higher odds of work-related burnout were found for nurses (AOR 1.5; 95%CI 1.2 to 1.9) and residents (AOR 1.9; 95%CI 1.04 to 3.6). Basic scientists (AOR 10.0; 95%CI 5.7 to 17.6), physicians (AOR 2.8; 95%CI 1.9 to 4.1) and nurses (AOR 2.1; 95%CI 1.3 to 3.5) had higher odds of patient/client-related burnout. CONCLUSIONS: Types of burnout are unevenly distributed in academic medical centres. Physicians have higher risk of personal and patient/client-related burnout, residents have higher risk of work-related burnout, basic scientists are at higher risk of client-related burnout and nurses have higher odds of all three types of burnout. Interventions addressing the problem of burnout in clinical environments may be inadequate to support biomedical scientists.

Emerging Trends in Pain Medication Management: Back to the Future: A Focus on Ketamine.

Providers face many challenges when faced with pain management. Pain is complex, difficult to understand and diagnose, and especially enigmatic to manage. The discovery of nonopioid agents for pain management has become particularly important considering the ongoing opioid epidemic. This review is focused on revisiting ketamine, an agent that has historically been used for anesthesia, in new ways to manage pain. Ketamine has unique pharmacologic properties that may prevent the development of pain as well as reduce chronic pain. This has led to the use of ketamine for perioperative analgesia as well as chronic pain syndromes. In select patients with pain refractory to other treatment modalities, ketamine may provide much needed relief.

Old Friends With New Faces: Are Sodium Channel Blockers the Future of Adjunct Pain Medication Management?

Providers are being asked to decrease the emphasis and overutilization of long-term opioid therapy, but many are left without proper guidance on appropriate utilization of nonopioid therapies. Furthermore, therapeutic options are quite limited and many providers lack confidence in distinguishing available alternatives. When first-line therapy has failed in a patient, there is an apparent lack of knowledge on how to proceed with choosing subsequent therapy. To choose among alternative agents, an understanding of pharmacology, pharmacokinetics, and efficacy in targeting various pain conditions is necessary. This article focuses on the use of the carboxamide class of sodium channel blockers (carbamazepine, oxcarbazepine, eslicarbazepine) for adjunct pain medication management including research updates in pharmacology, pharmacokinetics, and current evidence for pain along with promising areas of research. It is an evidence update for clinical use of sodium channel blockers, clarifies misconceptions regarding their use, and highlights emerging research for improved pain targets that justifies additional study. We performed a complete review of the literature using the search terms, "oxcarbazepine," "carbamazepine," and "eslicarbazepine" in conjunction with "pharmacokinetics," "adverse effects," "pharmacology," "voltage-gated sodium channel subtype," "neuropathic pain," "inflammatory pain," "metabolism," "epoxide metabolite formation," "drug interactions," "CYP450 interactions," "pain phenotype," and "chronic pain management." Databases searched included PubMed and Google Scholar. Package inserts were used for drug structure illustration, adverse reactions, and bioavailability. Pharmacology and pharmacokinetic data were taken from randomized controlled trials evaluating this area as well as in vitro published results. For validity, only peer-reviewed literature was included. Evidence for sodium channel blockers in chronic pain management was limited. This review focuses on highlighting the data available for the use of sodium channel blockers for certain pain syndromes as well as underutilized potential. Emerging literature on sodium channel subtypes and their connection to neuropathic, inflammatory, and mechanical pain transmission is elucidated. The authors also scrutinize literature surrounding the pharmacokinetics of oxcarbazepine and eslicarbazepine to provide clearer guidance to the significance of any drug interactions and refute assumptions made on the basis of structural similarity to carbamazepine and its known undesirable drug interactions. Side effect profiles are outlined and compared, emphasizing the differences between agents. Sodium channel blocker doses used in certain pain syndromes are outlined with a call for further research to better understand their place in chronic pain management. Identification of sodium channel subtypes with links to specific pain conditions and the ability to target them hints at the potential for truly individualized therapy. Sodium channel inhibitors are underutilized on the basis of available evidence, and emerging research has identified this area as promising for additional clinical trials to better guide clinical practice. PERSPECTIVE: This article provides a review of the pharmacology, evidence for pain management, and pharmacokinetics of oxcarbazepine, carbamazepine, and eslicarbazepine. There is a disparity in evidence using sodium channel blockers for pain and this article highlights the potential that is currently underutilized. The authors believe this will catalyze interest for further studies.

Cystic Dysplasia of the Testis in an Intraabdominal Undescended Testicle.

Cystic dysplasia of the testis is a rare, benign pathologic finding. We present two recent cases of cystic dysplasia of the testis to our practice. The first case involves an 11 month old male presenting with a non-palpable, intra-abdominal left testis. The second case involves a 7 year old male with left scrotal swelling and a history of left renal agenesis. After review of the literature, the first case represents the first report of cystic dysplasia of the testis in an undescended, intra-abdominal testicle.

Variability in Opioid Equivalence Calculations.

OBJECTIVE: Equianalgesic conversion methods are commonly used to switch patients from one opioid to another due to suboptimal pain relief or adverse events. There is no universally accepted opioid conversion method, however, and there is often significant variability between conversion resources. As a result, patients are at risk for undertreated pain and serious adverse events. The purpose of this survey was to compare the equianalgesic conversion estimates between nurse practitioners, pharmacists, and physicians for commonly prescribed opioids. METHODS: A survey form was developed using Survey Monkey. Participation was solicited by providing a link to the survey via social media (e.g., Facebook, Twitter, LinkedIn, etc.) and emailing professional organizations for sharing with their members and followers. Data collected included demographics and estimated morphine equivalents (MEQs) of hydrocodone 80 mg, fentanyl transdermal patches 1,800 mcg (as 75 mcg/hour), methadone 40 mg, oxycodone 120 mg, and hydromorphone 48 mg. Participants were also asked to provide their choice of reference utilized to complete the conversions, including personal knowledge. Descriptive analyses were performed using measures of central tendency. Hypothesis testing was performed using Pearson's chi-squared and Fisher's Exact Test for categorical data and the Kruskal-Wallis equality of populations rank test for continuous data to assess differences between median opioid doses by professional groups. RESULTS: The total number of respondents included in the analysis was 319. Physicians, pharmacists, and nurse practitioners/physician assistants comprised 25.4%, 56.7%, and 16.3%, respectively, of respondents. The overall mean (± standard deviation) MEQ doses for fentanyl, hydrocodone, hydromorphone, methadone, and oxycodone were: 176 (±117) mg, 88 (±42) mg, 192 (±55) mg, 193 (±201) mg, and 173 (±39) mg, respectively. For fentanyl, the mean (±standard deviation) MEQ doses were 180 (±122) mg, 178 (±128) mg, and 157 (±68) mg, for physicians, pharmacists, and nurse practitioners/physician assistants, respectively. For all three groups of clinicians, the median MEQ dose for fentanyl was 150 mg. The mean (±standard deviation) MEQ doses of methadone for physicians, pharmacists, and nurse practitioners/physician assistants were: 214 (±142) mg, 171 (±107) mg, and 185 (±129) mg, respectively. The median MEQ dose for methadone was 160 mg for each of the clinician groups. CONCLUSIONS: As evidenced by large standard deviations, there was significant variation in mean opioid conversions to MEQ doses within each profession type, particularly for fentanyl and methadone. The median MEQ doses provided for opioid conversions were the same among each profession. No universal method exists that allows each of the five studied opioids to be accurately and consistently converted to another opioid (i.e., morphine).