Postdischarge Opioid Prescription after Cesarean: A Quality Improvement Initiative.

OBJECTIVE: This study aims to determine if adoption of a user-friendly algorithm for individualized opioid prescribing at discharge would decrease the number of opioids prescribed after cesarean delivery. STUDY DESIGN: As part of a quality initiative, we developed and implemented an algorithm for opioid prescribing at discharge for patients after cesarean delivery. The intervention group comprised patients delivering by cesarean in the 6 months following initiation of the intervention. The intervention group was divided into three groups based on inpatient opioid needs 24 to 48 hours after delivery. Oxycodone tablets were prescribed at discharge based on inpatient group. The control group comprised patients delivering at the same institution in the 6 months prior to initiation of the intervention. The primary outcome was number of oxycodone tablets prescribed at discharge. The secondary outcome was the proportion of patients with a pain-related encounter or additional oxycodone prescription up to 6 weeks after delivery. RESULTS: From July to December 2020, a total of 382 subjects met criteria for the intervention. The comparison group consisted of 391 subjects discharged from January to June 30, 2020, after cesarean. Baseline characteristics and inpatient opioid use 24 to 48 hours after delivery did not differ between the groups. Compared with the control group, subjects in the intervention group had fewer oxycodone tablets prescribed at discharge (11.1 vs. 15.8, p < 0.001). The number of pain-related encounters within 6 weeks of delivery did not differ between the intervention and comparison groups (10.5 vs. 10.3%, p = 0.82). There was no increase in the additional number of oxycodone prescriptions after discharge (4.7% in the intervention group vs. 4.3% in the control group, p = 0.81). CONCLUSION: Discharge opioid prescribing based on inpatient use after cesarean reduces the number of opioids prescribed without increasing the number of pain-related encounters after discharge. A simple algorithm may ensure compliance from prescribers. KEY POINTS: · Previous research has shown that most opioids prescribed after cesarean delivery are unused after discharge. We implemented an algorithm for opioid discharge prescribing after cesarean delivery based on inpatient opioid consumption.. · Implementing an individualized approach to opioid prescribing reduced the number of tablets prescribed at discharge after cesarean delivery. The decrease in discharge prescribing did not correspond to an increase in pain-related encounters or additional narcotic prescriptions in the 6 weeks following delivery.. · The overprescription of opioids at discharge after cesarean delivery is well-established, and previous authors have found success in prescribing opioids at discharge based on inpatient use. Our study proposes a simple, reproducible algorithm for opioid prescribing at discharge after cesarean..

Fecal Incontinence and the Risk of Urinary Tract Infection in Patients Presenting for Urogynecological Consultation.

IMPORTANCE: Urinary tract infection (UTI) is common in urogynecology patients. Patients with fecal incontinence (FI) often attribute their UTIs to FI, but this association has not been evaluated. OBJECTIVES: The objectives of this study were to compare the prevalence of UTI in urogynecology patients with and without FI and to characterize factors associated with UTI and recurrent UTI. STUDY DESIGN: This retrospective cohort study included all new adult patients who presented to an academic female pelvic medicine and reconstructive surgery practice with FI from January 2014 through December 2017. Patients were age-matched to new adult patients with stage <2 pelvic organ prolapse without FI. All urine culture results from 1 year before and 1 year after the first visit were identified. Logistic regression identified factors associated with UTI. RESULTS: Among 399 patients, 106 (27%) had a culture-confirmed UTI in the year before or after their first urogynecology visit; the prevalence of UTI was 23% (45/198) in patients with FI and 30% (61/201) in those without FI (P = 0.09). The rate of recurrent UTI was 11.5% overall and did not differ among those with and without FI. In multivariate models, variables that were statistically significantly associated with UTI included age, diabetes mellitus, anterior vaginal wall prolapse, and sexual activity. Fecal incontinence was not associated with any or recurrent UTI. CONCLUSIONS: The prevalence of UTI and recurrent UTI was similar in urogynecology patients with and without FI. Variables that were associated with UTI risk included older age, sexual activity, diabetes mellitus, and anterior vaginal wall prolapse.

The obesity paradox in pulmonary arterial hypertension: the Scottish perspective.

Analysis of pulmonary arterial hypertension patients in Scotland across 20 years supports a recent French study suggesting there is no protective effect from obesity for this disease, in contrast to emerging evidence from the USA and China http://bit.ly/34WCZ7W.

Social deprivation and prognosis in Scottish patients with pulmonary arterial hypertension.

Several demographic and clinical factors have prognostic significance in idiopathic pulmonary arterial hypertension (IPAH). Studies in China and the USA have suggested an association between low socioeconomic status and reduced survival. The impact of social deprivation on IPAH survival in the UK is not known.280 patients with IPAH and hereditary PAH (HPAH) attending the Scottish Pulmonary Vascular Unit (Glasgow, UK) were assigned to social deprivation quintiles using the Scottish Index of Multiple Deprivation database. The association between survival and social deprivation quintile was assessed using Cox proportional hazards regression analysis.The distribution of IPAH/HPAH patients was more socially deprived than would be expected based on Scottish citizenry as a whole (Chi-squared 16.16, p=0.003), suggesting referral and access to care is not impeded by socioeconomic status. Univariate analysis demonstrated no significant association between social deprivation and survival (p=0.81), and this association failed to reach significance with inclusion of time, sex and age as covariates in the model (p=0.23). There were no statistically significant correlations between social deprivation and baseline clinical variables of prognostic importance except for age, sex and quality of life.Social deprivation is not a significant referral barrier or prognostic factor for IPAH and HPAH in Scotland.