Medication-assisted recovery for opioid use disorder: A guide.

Considering offering medical intervention for OUD to reduce mortality? It's essential to understand the clinical benefits, limitations, and regulation of available agents.

DOsing Strategy Effectiveness of Diltiazem in Atrial Fibrillation With Rapid Ventricular Response.

STUDY OBJECTIVE: To evaluate the dose-dependent comparative safety and effectiveness between weight-based and alternative dosing strategies for diltiazem in atrial fibrillation with rapid ventricular response. METHODS: This retrospective cohort study included adult patients presenting to the emergency department (ED) with atrial fibrillation with rapid ventricular response who received treatment with intravenous diltiazem. Groups were retrospectively categorized according to the initial dose: low (<0.1875 mg/kg), weight-based (0.1875 to 0.3125 mg/kg), and high (>0.3125 mg/kg). The primary outcome was rate control (heart rate <100 beats/min) within 30 minutes of treatment. RESULTS: Of 345 records, 252 were included. Because of scarcity (N=6), outcomes for the high-dose group were not analyzed. By 30 minutes, the weight-based dosing group had more often achieved rate control (weight-based 55%; low 27%; difference 29% [95% confidence interval (CI) 17% to 40%]). Regression analysis identified the weight-based dosing group (odds ratio 3.63, 95% CI 2.06 to 6.39) and initial heart rate of less than 145 beats/min (odds ratio 2.56, 95% CI 1.46 to 4.51) as variables associated with the primary outcome. The weight-based dosing group less often required rescue therapy (weight-based 6%; low 17%; difference -12% [95% CI -20% to -4%]) relative to the low-dose group. Mortality was higher in the low-dose group than in the weight-based dosing group (low 7%; weight-based 1%; difference 6% [95% CI 1% to 11%]). CONCLUSION: This study shows dose-dependent hemodynamic effects with diltiazem in patients with atrial fibrillation with rapid ventricular response. Weight-based diltiazem (0.25 mg/kg) was associated with greater rate control with no evidence of increased adverse effects. There was no perceived advantage in using lower, alternative doses.

Poor guideline adherence in a real-world evaluation of hypertensive emergency management.

BACKGROUND: The American College of Cardiology and American Heart Association define hypertensive emergency (HTN-E) as a systolic blood pressure greater than 180 mmHg or a diastolic blood pressure greater than 120 mmHg with evidence of end-organ damage (EOD). Based on expert opinion, current guidelines recommend antihypertensive therapy to reduce blood pressure (BP) at specific hourly rates to reduce progression of EOD, outlined by four criteria. Our goal was to describe compliance with guideline recommendations for early management of HTN-E and to analyze safety outcomes related to pharmacologic intervention. METHODS: This was a retrospective chart review including patients presenting to the emergency department with HTN-E between September 2016 and August 2020. We excluded patients with a compelling indication for altered therapeutic goals (e.g. acute aortic dissection, hemorrhagic or ischemic stroke, and pheochromocytoma). The primary outcome was complete adherence with guideline recommendations in the first 24 h. RESULTS: Of 758 screened records, 402 were included. Mean age was 54 years and majority Black race (72%). Overall, total adherence was poor (<1%): 30% received intravenous therapy within 1 h, 64% achieved 1-h BP goals, 44% achieved 6-h goals, and 9% had appropriate 24-h maintenance BP. Hypotensive events (N = 67) were common and antihypertensive-associated EOD (N = 21) did occur. Predictors of hypotension include treatment within 1 h and management with continuous infusion medication. CONCLUSIONS: Current practice is poorly compliant with guideline criteria and there are risks associated with recommended treatments. Our results favor relaxing the expert opinion-based recommendations.

Anion gap physiology and faults of the correction formula.

PURPOSE: The anion gap is a calculated fundamental laboratory parameter used to identify and monitor acid-base disturbances. A recently popularized correction formula transforms the resulting integer to compensate for hypoalbuminemia and improve diagnostic yield. Clinical pharmacists should be aware of the underlying biochemistry, interpretation, and limitations of this formula to discern drug- and disease-related etiologies. SUMMARY: The anion gap is utilized in most care settings, ranging from outpatient monitoring to inpatient intensive care units. Supported by decades of experience, the original anion gap derives its value from its simplicity. Applying the anion gap in metabolic acidosis can help narrow differential diagnosis and detect concomitant acid-base disorders. To account for hypoalbuminemia and potential missed diagnoses, a correction formula was developed to improve sensitivity. Yet, the law of electroneutrality ensures that hypoalbuminemia is already accounted for in the original anion gap, and the proposed correction formula was derived from samples unrepresentative of human physiology. Evidence from clinical trials shows no benefit from applying the correction formula. CONCLUSION: There is no advantage to correcting the anion gap, and such correction may increase the risk of misinterpretation or error. Clinicians should understand these limitations when diagnosing or trending acid-base disturbances.

The Impact of Body Weight and Renal Function on the Risk of Bleeding With Direct Oral Anticoagulants in Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) increases the risk of stroke and direct oral anticoagulants (DOACs) are first-line agents for prevention. Gaps in the literature cause reluctance in prescribing DOACs for patients with renal dysfunction and/or extremes in body weight. OBJECTIVE: To evaluate the impact body weight and renal function have on major and clinically relevant nonmajor (CRNM) bleeding events and ischemic strokes in AF patients receiving a DOAC. METHODS: This retrospective cohort study included adults with nonvalvular atrial fibrillation (NVAF) or atrial flutter (AFL) receiving a DOAC ≥12 months. The primary outcome was a composite of major and CRNM bleeding events. Secondary outcomes included ischemic stroke and risk factors for bleeding events. RESULTS: Of the 233 patients analyzed, 25 patients experienced a bleeding event. Patients who bled weighed 10 kg less (P = 0.043) than those who did not and had a higher HASBLED score (P = 0.003). Multivariate logistic regression identified weight (P = 0.048), serum creatinine (SCr; P = 0.027), and HASBLED score (P = 0.024) as the significant predictors for experiencing a bleed. Three patients experienced a stroke. CONCLUSION AND RELEVANCE: This study demonstrates an association between higher baseline SCr, elevated HASBLED score, and lower weight, with an increased risk of bleeding in patients with NVAF or AFL receiving a DOAC. These findings add to prescribing considerations when initiating DOACs. Closer monitoring is advised for patients with significant renal dysfunction and/or low body weight, even with renal dose adjustments.

Phenylethanolamine N-methyltransferase gene polymorphisms associate with crisis pain in sickle cell disease patients.

Aim: Phenylethanolamine N-methyltransferase (PNMT) catalyzes the conversion of sympathetic neurotransmitter norepinephrine to epinephrine. We examined the association of PNMT polymorphisms with acute and chronic pain in sickle cell disease (SCD). Methods: Utilization of emergency care owing to painful crisis was used as a marker for acute pain in 131 patients with SCD. Results: rs876493 A allele, rs2934965 T allele and rs2941523 G allele were significantly associated with decreased utilization (p ≤ 0.05). rs876493 A allele showed association with utilization in females (p = 0.003), not males (p = 0.803). rs2934965 T allele and rs2941523 G allele were predicted to cause loss of putative transcription factor binding sites. This is the first report of the association of PNMT polymorphisms with acute crisis pain in SCD. Together with our previous findings in catechol-o-methyltransferase, polymorphisms in catecholamine metabolizing enzymes appear to primarily influence acute pain in SCD.

Workplace accommodations for persons with physical disabilities: evidence synthesis of the peer-reviewed literature.

PURPOSE: To identify and synthesize research evidence on workplace accommodations used by employers to recruit, hire, retain, and promote persons with physical disabilities. METHOD: A structured search of six electronic journal databases was undertaken to identify peer-reviewed literature on the topic published from January 1990 to March 2016. Articles describing or evaluating workplace disability accommodation policies and practices were given a full-text review. Topic experts were contacted to identify additional studies. RESULTS: Details on specific accommodations described in 117 articles were synthesized and organized into three groups comprised of a total of 12 categories. The majority of studies did not rigorously evaluate effectiveness or cost-effectiveness of the accommodations under study. CONCLUSIONS: This evidence synthesis provides an overview of the peer-reviewed literature of value to occupational rehabilitation professionals and employers seeking guidance on workplace accommodation policies and practices for persons with physical disabilities. A wide range of accommodation options is available for addressing physical, social, and attitudinal barriers to successful employment. Besides physical/technological modifications, accommodations to enhance workplace flexibility and worker autonomy and strategies to promote workplace inclusion and integration are important. More comprehensive reporting and evaluations of the effectiveness of accommodations in research literature are needed to develop best practices for accommodating persons with disabilities. Implications for rehabilitation There is a substantial peer-reviewed literature that provides insights into the barriers for persons with physical disabilities and the workplace accommodation practices to address them, though rigorous evaluations of effectiveness and cost-effectiveness are uncommon. Attitudinal and social barriers stemming from stereotypes, ignorance and lack of knowledge are as important as physical barriers to employment for persons with physical disabilities. In addition to physical/technological modifications, accommodations to enhance workplace flexibility and autonomy of a worker, as well as strategies to promote workplace inclusion and integration may facilitate successful employment of persons with physical disabilities.