Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane Blocks in Abdominally Based Microvascular Breast Reconstruction.

BACKGROUND: Transversus abdominis plane blocks can improve pain control and decrease opioid use within an enhanced recovery after surgery (ERAS) protocol in patients undergoing abdominally based autologous breast reconstruction. The authors have transitioned to using a local analgesic cocktail for transversus abdominis plane blocks. The purpose of this study was to compare postoperative opioid use in patients who received the blocks. METHODS: Patients who underwent abdominally based autologous breast reconstruction between November of 2015 and December of 2019 were retrospectively reviewed. The study group received bupivacaine, ketorolac, dexmedetomidine, and dexamethasone; the control group received liposomal bupivacaine with or without bupivacaine, ketorolac, or dexmedetomidine, as a transversus abdominis plane block. The primary outcome of interest was postoperative opioid use and pain scores. RESULTS: One hundred four women met inclusion criteria: 36 in group A (before ERAS, before transversus abdominis plane block), 38 in group B (ERAS, transversus abdominis plane block with liposomal bupivacaine), and 30 in group C (ERAS, transversus abdominis plane block with local anesthetic cocktail). Total daily oral morphine equivalent consumption (group A, 633; group B, 240; group C, 135; p < 0.0001) and average daily oral morphine equivalent consumption (group A, 137; group B, 56; group C, 29; p < 0.0001) were significantly less for group C in the inpatient phase. Patients in group C were prescribed significantly fewer outpatient oral morphine equivalents (group A, 79; group B, 74; group C, 52; p = 0.01). CONCLUSIONS: Transversus abdominis plane blocks are a significant component of an ERAS protocol for abdominally based breast reconstruction. Liposomal bupivacaine is a popular option for transversus abdominis plane blocks. The authors' results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease postoperative opioid use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prescribing patterns and outcomes among patients treated for gestational diabetes mellitus.

Insulin is recommended as first-line pharmacologic therapy for gestational diabetes (GDM); however, glyburide and metformin are often used. This study aimed to identify the most commonly prescribed agents for treating GDM, along with the maternal and fetal outcomes associated with their use. Electronic medical records were used to identify the medications prescribed for GDM at a large health system. Data were collected comparing medication failure rate, maternal weight gain, and incidence of fetal macrosomia, neonatal hypoglycemia, and premature delivery between the agents used. Of the 368 patients who met the inclusion criteria, 76.9% were initiated on glyburide, 13.6% were initiated on metformin, 8.2% were initiated on insulin, and 1.4% were initiated on a combination of glyburide and metformin. Glyburide was associated with less medication failure compared to insulin and metformin. There was no significant difference in maternal weight gain, fetal macrosomia, or neonatal hypoglycemia between the three classes of medications. However, recipients of basal and bolus insulin had a higher rate of preterm delivery compared to recipients of glyburide and metformin. Our findings suggest that glyburide and metformin are frequently prescribed over insulin as the initial treatment for GDM and appear to be safe and effective alternatives.

Depression screening and treatment among uninsured populations in Primary Care / Detección y tratamiento de la depresión en poblaciones sin seguro médico en Atención Primaria

Uninsured populations have poor treatment engagement and are less likely to receive evidence-based interventions for depression. The objective of the current study was to retrospectively examine depression screening, diagnosis, and treatment patterns among uninsured patients in primary care. Study sample included all patients (N=11,803) seen in nine community-based clinics. Key variables included depression screener and/or a depression diagnosis, anti-depressant initiation, behavioral health visits, and patient follow up measures. Treatment patterns from the subsample of patients diagnosed with depression were analyzed by collecting the number of behavioral health visits and antidepressant use six months (180 days) following the diagnosis. Utilization of the depression screening tool was high (67%, n=7,935) and 24% (n=2,789) of the patients had a diagnosis of depression, however, more than half of the patients with a depression diagnosis did not have a recorded treatment plan (n=1,474). The odds of anti-depressant use and behavioral visits for Hispanic patients were significantly greater than for Non-Hispanic patients. Universal screening with brief measures in primary care is improving, however, guideline-concordant depression treatment remains elusive for uninsured populations. (AU)

Poblaciones sin seguro médico tienen un compromiso deficiente con el tratamiento médico y menos probabilidad de recibir intervenciones basadas en evidencia para la depresión. El objetivo fue examinar retrospectivamente detección, diagnóstico y tratamiento de depresión entre pacientes sin seguro médico en Atención Primaria. Se incluyó a pacientes (N=11.803) atendidos en nueve clínicas comunitarias. Las variables fueron detección de depresión y/o diagnóstico de depresión, inicio del consumo de antidepresivos, visitas al proveedor de salud mental y medidas de seguimiento. Los planes de tratamiento de una submuestra de pacientes con depresión se analizaron mediante la recopilación del número de visitas a salud mental y uso de antidepresivos durante seis meses después del diagnóstico. La utilización de la herramienta de detección de depresión fue alta (67%, n=7.935) y 24% (n=2.789) en pacientes diagnosticados de depresión. Más de la mitad de los pacientes no tenían plan de tratamiento registrado (n=1.474). Las probabilidades de uso de antidepresivos y visitas a proveedores de salud mental para pacientes hispanos fueron mayores que para pacientes no hispanos. La detección universal con medidas breves en Atención Primaria está mejorando, pero el tratamiento de la depresión sigue siendo difícil de alcanzar para poblaciones sin seguro. (AU)

Depression screening and treatment among uninsured populations in Primary Care.

Uninsured populations have poor treatment engagement and are less likely to receive evidence-based interventions for depression. The objective of the current study was to retrospectively examine depression screening, diagnosis, and treatment patterns among uninsured patients in primary care. Study sample included all patients (N = 11,803) seen in nine community-based clinics. Key variables included depression screener and/or a depression diagnosis, anti-depressant initiation, behavioral health visits, and patient follow up measures. Treatment patterns from the subsample of patients diagnosed with depression were analyzed by collecting the number of behavioral health visits and antidepressant use six months (180 days) following the diagnosis. Utilization of the depression screening tool was high (67%, n = 7,935) and 24% (n = 2,789) of the patients had a diagnosis of depression, however, more than half of the patients with a depression diagnosis did not have a recorded treatment plan (n = 1,474). The odds of anti-depressant use and behavioral visits for Hispanic patients were significantly greater than for Non-Hispanic patients. Universal screening with brief measures in primary care is improving, however, guideline-concordant depression treatment remains elusive for uninsured populations.

Poblaciones sin seguro médico tienen un compromiso deficiente con el tratamiento médico y menos probabilidad de recibir intervenciones basadas en evidencia para la depresión. El objetivo fue examinar retrospectivamente detección, diagnóstico y tratamiento de depresión entre pacientes sin seguro médico en Atención Primaria. Se incluyó a pacientes (N = 11.803) atendidos en nueve clínicas comunitarias. Las variables fueron detección de depresión y/o diagnóstico de depresión, inicio del consumo de antidepresivos, visitas al proveedor de salud mental y medidas de seguimiento. Los planes de tratamiento de una submuestra de pacientes con depresión se analizaron mediante la recopilación del número de visitas a salud mental y uso de antidepresivos durante seis meses después del diagnóstico. La utilización de la herramienta de detección de depresión fue alta (67%, n = 7.935) y 24% (n = 2.789) en pacientes diagnosticados de depresión. Más de la mitad de los pacientes no tenían plan de tratamiento registrado (n = 1.474). Las probabilidades de uso de antidepresivos y visitas a proveedores de salud mental para pacientes hispanos fueron mayores que para pacientes no hispanos. La detección universal con medidas breves en Atención Primaria está mejorando, pero el tratamiento de la depresión sigue siendo difícil de alcanzar para poblaciones sin seguro.

Anxiety sensitivity, COVID-19 fear, and mental health: results from a United States population sample.

The COVID-19 pandemic has resulted in unprecedented consequences. Transdiagnostic factors, such as anxiety sensitivity, could be an important component to understand how individuals experience COVID-19 specific fear, depression and anxiety. A US representative sample (5,023) completed measures including the Anxiety Sensitivity Index-3, the Fear of COVID-19 Scale, the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-8. Analyses controlled for age, sex, race, marital status, education level, working status, household income, and COVID-19 exposure. Results were consistent with prediction. First, higher ASI-3 Total scores were associated with above average COVID-19 fear (ß = 0.19). Second, the ASI-3 physical concerns subscale was the strongest predictor of COVID-19 fear; one SD increase on the ASI-3 physical concerns subscale was associated with almost a twofold risk of reaching above average levels of COVID-19 (OR = 1.93). Third, higher ASI-3 Total scores were associated with higher anxiety (ß = 0.22) and depression (ß = 0.20). Finally, COVID-19 fear mediated the relationship between ASI-3 Total scores and anxiety (17% of effect mediated) as well as ASI-3 Total scores and depression (16% of effect mediated). These data support the role of anxiety sensitivity in predicting fear of COVID-19 and resulting mental health.

Comparisons Between Patients Diagnosed with PTSD in Primary Care Versus Mental Health Care in Five Large Civilian Health Care Systems.

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that may not be adequately detected or treated in primary care (PC). The purpose of this study was to compare the clinical characteristics and health care utilization of PTSD patients diagnosed in PC versus in specialty mental health care (MHC) across five large, civilian, not-for-profit healthcare systems. Electronic claims and medical record data on patients treated during 2014 were analyzed. Treatment was considered in terms of initiation and dose (i.e., psychotherapy sessions; pharmacotherapy-prescription psychotropics). Of 5256 patients aged 15-88 with a diagnosis of PTSD, 84.4% were diagnosed by a MHC provider. Patients diagnosed by MHC providers had 4 times the rate of and more enduring psychotherapy than those diagnosed by PC providers. Receipt of psychotropics varied by provider type, with generally higher prescription fill levels for patients in MHC. Strategies to better align patient needs with access and treatment modality in PC settings are needed.

Corticosteroid Dosing and Glucose Levels in COPD Patients Are Not Associated with Increased Readmissions.

INTRODUCTION: Hospital admissions and readmissions for chronic obstructive pulmonary disease (COPD) exacerbations are associated with increased mortality and higher cost. The management of exacerbations with a shortened course of systemic corticosteroids has similar efficacy as compared to longer steroid courses, but actual overall steroid dose given is still variable. The outcomes associated with steroid side effects, such as hyperglycemia, need further evaluation. We hypothesized that the use of higher doses of corticosteroids, and the subsequent hyperglycemia, contributes to readmission. METHODS: This is a retrospective study at a tertiary care referral center in central Texas between February 2014 and July 2016. Daily corticosteroid dose, blood glucose levels, and readmission rates at 30 and 31-90 days were recorded. Sample characteristics are described using descriptive statistics. A chi-square test or student's t-test were used to test for associations in bivariate comparisons. Multivariable logistic regression assessed the association between readmission rate and demographic and clinical characteristics. RESULTS: There were 1120 patients admitted for COPD exacerbation between February 2014 and July 2016. A total of 57% were female, mean age was 69 years (standard deviation [SD] 12), and average body mass index (BMI) was 29.4 (SD 9.8). Of the total, 349 (31%) had diabetes prior to admission. The 30-day readmission rate was 16%, and the readmission rate from 31-90 days was 14%. The average prednisone equivalent dose per day during hospitalization was 86 mg (SD 52). A multivariable logistic regression model did not show any significant association between readmission and average daily glucose, high maximum glucose (>180 mg/dL on any reading), or prednisone equivalent administered per day. CONCLUSION: Corticosteroid dose and hyperglycemia were not associated with an increased 30-day or 31-90-day readmission rate after COPD exacerbation discharge. In addition, using higher doses of corticosteroids instead of standard-of-care (prednisone 40 mg per day for a 5-day period) did not appear to affect the readmission rate in this cohort.

Quality improvement initiative for pain management practices in primary care.

In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.

Bedside risk stratification for mortality in patients with acute respiratory failure treated with noninvasive ventilation.

Our hypothesis was that patients managed with noninvasive ventilation (NIV) on the wards could be risk-stratified with initial pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratios and tidal volumes (Vte). A prospective study of consecutive patients with acute respiratory failure requiring NIV on the wards was conducted. A multivariate logistic regression model and a negative binomial regression model were used. A total of 403 patients (55.8% women) had a mean age of 65.0 ± 14.9 years with a mean body mass index of 32.1 ± 11.1 kg/m2. The 28-day mortality was 14.1%, and the intubation rate was 16.1%. Pneumonia was associated with the highest 28-day mortality (22.5%) and rate of intubation (36.7%) when compared with chronic obstructive pulmonary disease (4.4% and 7.3%) or congestive heart failure (22.2% and 13.4%). The SpO2/FiO2 groups were <214 (26.6%), 214 -357 (66.0%), and ≥357 (7.4%). Those in the SpO2/FiO2 < 214 group had a higher 28-day mortality rate (odds ratio [OR] = 8.19; 95% confidence interval [CI] 1.02 -65.7), intubation rate (OR = 3.7; 95% CI 1.1 -12.1), intensive care unit admission rate (OR = 2.9; 95% CI 1.2 -7.4), and length of stay (relative risk = 2.0; 95% CI 1.3 -3.0). A Vte/predicted body weight <7.7 mL/kg was associated with increased intubations (OR = 3.1; 95% CI 1.3 -7.4), intensive care unit admissions (OR = 2.5; 95% CI 1.3 -4.6), and 30-day readmissions (OR = 2.9; 95% CI 1.2 -6.8). In conclusion, in patients without acute respiratory distress syndrome who had acute respiratory failure managed with noninvasive ventilation on the wards, severe hypoxemia as assessed by a simple SpO2/FiO2 ≤ 214 was associated with poor outcomes.

Guidelines impact cholesterol management.

BACKGROUND: Previous research demonstrates increased utilization of high-intensity statins, but unchanged low-density lipoprotein cholesterol (LDL-C) levels, immediately after the 2013 American College of Cardiology (ACC) and the American Heart Association (AHA) guideline release. OBJECTIVE: The objective of this study was to determine achievement of statin therapy goals in patients with atherosclerotic cardiovascular disease (ASCVD) before and up to 4 years after the 2013 ACC/AHA guideline release compared with LDL-C goals of <70 mg/dL and <100 mg/dL previously recommended by other professional societies. METHODS: The single-system cohort study used medical records, laboratory results, and claims data (November 2012-October 2017) of adults with ≥1 claim for a statin, ≥1 ASCVD diagnosis in propensity score-matched analyses. RESULTS: Among 1938 patients (mean age 70 ± 11, 48% female) with ASCVD, the percentage on high-intensity statin therapy significantly increased over time: 24% in 2013, 34% 2014, 42% 2015, and 49% 2016 (P < .0001). The increase in high-intensity statin use was 13 to 22% higher among patients managed by subspecialists (cardiologist and endocrinologists) compared with those managed by primary care providers. Mean LDL-C level was slightly, but not significantly, lower in 2013 (80 mg/dL) than in other years: 85 mg/dL in 2014, 83 mg/dL in 2015, and 82 mg/dL in 2016. The proportion of patients reaching LDL-C goals ranged from 51% to 56% for the <70 mg/dL target and 77% to 85% for the <100 mg/dL target over time. CONCLUSION: High-intensity statin use among secondary prevention patients increased significantly immediately after the 2013 ACC/AHA guidelines release, primarily in those managed by subspecialists. However, the mean LDL-C and the proportion of patients reaching LDL-C < 70 mg/dL and < 100 mg/dL remain unchanged across comparison cohorts.

Does recipient work status pre-transplant affect post-heart transplant survival? A United Network for Organ Sharing database review.

BACKGROUND: Recipient-related factors, such as education level and type of health insurance, are known to affect heart transplantation outcomes. Pre-operative employment status has shown an association with survival in abdominal organ transplant patients. We sought to evaluate the effect of work status of heart transplant (HTx) recipients at the time of listing and at the time of transplantation on short- and long-term survival. METHODS: We evaluated the United Network for Organ Sharing (UNOS) registry for all adult HTx recipients from 2001 to 2014. Recipients were grouped based on their work status at listing and at heart transplantation. Kaplan-Meier estimates illustrated 30-day, 1-year, 5-year, and 10-year survival comparing working with non-working groups. The Cox proportional hazards regression model was applied to adjust for covariates that could potentially confound the post-transplantation survival analysis. RESULTS: Working at listing for HTx was not significantly associated with 30-day and 1-year survival. However, 5- and 10-year mortality were 14.5% working vs 19.8% not working (p < 0.0001) and 16% working vs 26% not working (p < 0.0001), respectively. Working at HTx appeared to be associated with a survival benefit at every time interval, with a trend toward improved survival at 30 days and 1 year and a significant association at 5 and 10 years. Kaplan-Meier analysis demonstrated a 5% and 10% decrease in 5- and 10-year mortality, respectively, for the working group compared with the group not working at transplantation. The Cox proportional hazards regression model showed that working at listing and working at transplantation were each associated with decreased mortality (hazard ratio [HR] = 0.8, 95% confidence interval [CI] 0.71 to 0.91; and HR = 0.76, 95% CI 0.65 to 0.89, respectively). CONCLUSIONS: This study is the first analysis of UNOS STAR data on recipient work status pre-HTx demonstrating: (1) an improvement in post-transplant survival for working HTx candidates; and (2) an association between working pre-HTx and longer post-HTx survival. Given that work status before HTx may be a modifiable risk factor for better outcomes after HTx, we strongly recommend that UNOS consider these important findings for moving forward this patient-centered research on work status. Working at listing and working at HTx are associated with long-term survival benefits. The association may be reciprocal, where working identifies less ill patients and also improves well-being. Consideration should be given to giving additional weight to work status during organ allocation. Work status may also be a modifiable factor associated with better post-HTx outcomes.