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Common Bacterial Infections in Persons Who Inject Drugs
No full textOpioid use in the United States has increased dramatically. Bacterial infections are common among persons who inject drugs (PWID), and there is a disparity in the care these individuals receive. As such, outcomes associated with these infections can be poor. Healthcare providers can address these disparities through optimal pharmacotherapy recommendations and assistance with changing approaches to the management of PWID.
Keywords: endocarditis; infections; opioid use disorder
Barriers to accessing medications for opioid use disorder among rural individuals
No full textBackground: Individuals with opioid use disorder living in rural areas face barriers to accessing medications for treatment (MOUD), including finding prescribing clinicians and difficulties with transportation. This study sought to describe self-reported barriers to MOUD access in rural areas and associations between desired MOUD type and barriers encountered or perceived.
Methods: We performed a cross-sectional study of Rural Opioid Initiative participants who ever used opioids and sought MOUD treatment, who were surveyed from 2018 to 2020 about access to MOUD. Multivariable logistic regressions explored the association between MOUD type and barriers while controlling for age, gender, race, and study site.
Results: Of 2906 participants who used opioids and sought MOUD, 826 (28.4 %) were unable to access MOUD. In logistic regression models, lack of transportation was a more common barrier for those seeking methadone versus sublingual buprenorphine (adjusted odds radio [aOR] 1.87, 95 % confidence interval (CI) 1.24-2.81). A long wait list was more common for those seeking injectable naltrexone than sublingual buprenorphine (aOR 1.68, 95 % CI 1.05-2.69). Lack of doctors or programs and affordability were more common for those seeking injectable versus sublingual buprenorphine (aOR 7.84, 95 % CI 4.87-12.63 and aOR 1.89, 95 % CI 1.26-2.83, respectively).
Conclusions: Access barriers vary by MOUD type for rural individuals with OUD. Compared to sublingual buprenorphine, methadone access was hindered more by transportation difficulties, while injectable long-acting buprenorphine was hindered more by affordability and finding a doctor or program. These barriers highlight the need to de-regulate and expand locations for methadone access and prescribing, and to improve affordability and prescriber uptake of newer MOUDs, such as injectable buprenorphine.
Keywords: Affordability; Barriers to opioid use disorder treatment; Medications for opioid use disorder; Rural healthcare; Transportation
Immediate transcatheter aortic valve replacement versus temporizing balloon aortic valvuloplasty in severe aortic stenosis: A systematic review and meta-analysis immediate TAVR vs. temporizing BAV
No full textBackground: Transcatheter aortic valve replacement (TAVR) is a first-line therapy for severe aortic stenosis (AS). In patients with contraindications to immediate TAVR, temporizing balloon aortic valvuloplasty (BAV) may be performed to stabilize patients prior to TAVR. The relative efficacy and safety of TAVR with or without temporizing BAV remains inadequately described.
Methods: We searched PubMed, Embase, and Cochrane databases for studies comparing TAVR with and without temporizing BAV in patients with severe AS. Random-effects models were used to calculate pooled odds, risk ratios (RRs) and mean differences with 95 % confidence intervals (CIs).
Results: Nine studies (59,205 patients: 95.7 % immediate TAVR, 4.3 % BAV + TAVR) met inclusion criteria. Mean age was 82.9 ± 6.6 years old, and 45.9 % were males. Patients in the TAVR group were a mean difference of 1 year younger with no difference in gender distribution between groups. Direct TAVR was associated with a lower risk of 30-day all-cause mortality than BAV + TAVR (RR = 0.62; 95 % CI 0.41 to 0.93; p = 0.02). There were no significant differences in risks of post-procedural pacemaker implantation, myocardial infarction, cardiac tamponade, major vascular complications, ischemic stroke, major bleeding, 2+ or greater aortic regurgitation grade or acute kidney injury.
Conclusion: While immediate TAVR was associated with slightly lower short-term mortality compared to BAV + TAVR in patients with severe AS, other binary endpoints were equivalent. This potential mortality difference should be considered when offering BAV + TAVR in patients with contraindications to immediate TAVR. Randomized studies are required to confirm these results.
Keywords: Aortic stenosis; Balloon aortic valvuloplasty; Transcatheter aortic valve implantation
Nursing News & Views - April/May 2025
Get PDFNursing News & Views - April/May 2025https://scholarlycommons.libraryinfo.bhs.org/nursing_newsletters/1044/thumbnail.jp
Venous access devices (Review)
No full textVenous access devices can be categorized based on the termination site of the tip of the catheter into central and peripheral access devices. Selecting the type of venous access device depends on various factors, including the condition of the patient, the anticipated duration of therapy, the use of vesicant or hyperosmolar therapies and the potential risk of complications. Peripheral intravenous catheters provide adequate venous access in the majority of hospitalized patients; however, their use is associated with high failure rates. Non-tunneled central venous access catheters are typically used in critically ill patients and are ideally suited for short-term use, while tunneled central catheters are utilized in those who require long-term intravenous therapy due to their extended dwell times. Each of these devices has unique characteristics requiring an in-depth understanding of the indications and current evidence-based recommendations to optimize their use. The present narrative review aimed to describe the different types of venous access devices and recommendations for their use based on current evidence-based recommendations. A narrative review of the literature was performed based on searches of the PubMed and Google Scholar database from 1990 through November 1, 2024. The type of device used, the insertion site, patient characteristics and clinical needs, and the risk of complications are factors that a provider needs to consider when ordering the placement of a venous access device are discussed. The present review also discusses the prevention of negative adverse events, such as bloodstream infections and thrombosis, associated with specific devices. In addition, current evidence-based recommendations for device selection and indications for use are described. The present narrative review provides a detailed examination of venous access devices that are essential in the care and treatment of patients. Since venous access is associated with inherent risks, device selection and meticulous post-insertion care are paramount in ensuring patient safety and successful therapy.
Keywords: non-tunneled central venous access catheters; peripheral intravenous catheters; tunneled central venous access catheters; venous access devices
Reply to Comment on: Mechanical outcomes of coronary stenting guided by intravascular ultrasound versus optical coherence tomography: A systematic review and meta-analysis with trial sequential analysis of randomized trials
No full textSerious Illness Conversations in the Emergency Department for Older Adults With Advanced Illnesses: A Randomized Clinical Trial
No full textImportance: Conversations between seriously ill patients and clinicians about values and goals (ie, serious illness conversations [SICs]) can lead to patient-centered care toward the end of life. However, many patients have not had SICs when arriving in the emergency department (ED) and are at risk of receiving undesired care.
Objective: To determine the effect of an ED-based, multimodal SIC intervention (known as ED GOAL) compared with usual care on patient-reported engagement in advance care planning (ACP) and clinician-documented SICs after leaving the ED.
Design, setting, and participants: This 2-armed, 1:1, parallel-design randomized clinical trial was conducted at 3 participating EDs (2 academic medical centers and 1 community hospital) in Boston, Massachusetts, within a single health system between March 1, 2022, and July 1, 2024, with a follow-up duration of 6 months. Eligible participants were English-speaking adults 50 years or older with serious illnesses, including mild cognitive impairment or mild dementia, along with their caregivers. For patients with moderate to severe dementia, caregivers were the primary participants in the study. Patients with documented goals for medical care or physician orders in the last 3 months in medical records or deemed clinically inappropriate by the treating ED team were excluded.
Intervention: SIC-trained research nurses conducted (1) a motivational interview about SICs, (2) a structured SIC, and (3) communication priming for the patients and their primary clinicians to reinitiate SICs on a tablet computer in the ED or within 1 week after leaving the ED.
Main outcomes and measures: The primary outcome was a validated survey of patient-reported engagement in ACP at 1 month, with total possible scores ranging from 1 to 5, with higher scores indicating more engagement. Secondary outcomes included clinician documentation of end-of-life values and preferences in the medical record and completed advance directives.
Results: A total of 141 patients (mean [SD] age, 66.7 [9.2] years; 73 [51.8%] female), predominantly diagnosed with metastatic cancer (85 [60.3%]), were enrolled and randomized to the intervention (n = 70) or usual care (n = 71). At 1 month, no difference was observed in patient-reported engagement in ACP (mean [SD] score, 3.32 [1.28] for control vs 3.37 [1.07] for intervention; maximum possible score, 5.00; P = .58), yet 12 patients in the intervention group (17.1%) discussed care preferences with their physicians compared with 5 (7.0%) control group patients (P = .07). Medical record documentation of end-of-life values and goals was significantly higher in the intervention group at 3 months (17 [24.3%] vs 7 [9.9%]; P = .03) and 6 months (22 [31.4%] vs 9 [12.7%]; P = .008).
Conclusions and relevance: In this randomized clinical trial of seriously ill older adults in the ED, while a nurse-led SIC intervention did not significantly improve patient-reported engagement in ACP, it did increase clinician-documented SICs in the medical records. ED visits may serve as a critical access point to enhance SICs for seriously ill yet clinically stable older adults.
Trial registration: ClinicalTrials.gov Identifier: NCT05209880
Pre-trauma insomnia and posttraumatic alcohol and cannabis use in the AURORA observational cohort study of trauma survivors
No full textBackground and aims: Insomnia symptoms are a potential risk factor for alcohol and cannabis use, particularly in trauma-exposed populations. The initial weeks and months after trauma are a period of risk for problematic substance use, however prior research has not examined whether insomnia symptoms predict alcohol or cannabis use after trauma.
Design: Using a large-scale, multi-site, prospective study of trauma survivors presenting to emergency departments (EDs), the current study tested direct and indirect associations between pre-trauma insomnia symptoms, two-week posttraumatic stress disorder (PTSD) symptoms, and eight-week post-trauma heavy alcohol and cannabis use and binge drinking.
Setting: Participants were recruited from 23 EDs in the United States and followed up using remote assessments.
Participants/cases: Participants were from the AURORA study (n = 2449). A slight majority were women (63.8 %) and were an average of 37 years old. Participants were racially and ethnically diverse (50.5 % Black, 11.2 % Hispanic).
Measurements: Participants completed self-report measures during their ED visit, and two- and eight-weeks post-trauma.
Findings: Pre-trauma insomnia symptoms significantly predicted eight-week post-trauma heavy alcohol and cannabis use, as well as binge drinking. Associations persisted after covarying for pre-trauma substance use, demographic variables, and trauma severity at the time of emergency care. Further, the association between pre-trauma insomnia symptoms and heavy alcohol and cannabis use at eight-weeks post-trauma was significantly mediated by two-week PTSD symptoms.
Conclusions: Insomnia symptoms may be an important malleable risk factor for heavy alcohol and cannabis use and binge drinking after trauma. Further research is needed to explore the effectiveness of insomnia interventions to mitigate post-trauma substance use and to better understand the complex relationships between sleep, trauma, PTSD, and substance use.
Keywords: Alcohol; Binge drinking; Cannabis; Insomnia; Posttraumatic stress disorder
The Role of Renal Denervation in HFpEF
No full textHeart failure with preserved ejection fraction (HFpEF) is a complex and heterogeneous clinical syndrome characterized by signs and symptoms of heart failure despite normal or near-normal ejection fraction. It is a debilitating chronic disease that affects millions of people worldwide, and due to the paucity of evidence-based pharmacological treatments for HFpEF, nonpharmacological approaches as potential therapeutic alternatives are of growing interest. As a result, renal denervation (RDN), initially developed as a therapeutic tool for resistant hypertension, has become an area of active clinical interest. RDN is a catheter-based procedure that targets the renal sympathetic pathways, aiming to reduce neurohormonal activation and mitigate maladaptive cardiac remodeling. Preclinical studies in animal models have demonstrated that RDN can improve cardiac and vascular fibrosis, reduce renal inflammation, control hypertension, and alleviate endothelial dysfunction. Recent clinical studies have further highlighted the potential benefits of RDN in patients with HFpEF and uncontrolled hypertension. In this review, we aim to outline the pathophysiology of HFpEF and demonstrate the complex clinical interplay involved in how RDN impacts the heart. Moreover, we discuss the present status of clinical studies on RDN and explore its therapeutic potential as a viable treatment for HFpEF.
Keywords: cardiac remodeling; heart failure with preserved ejection fraction; interventional cardiology approaches; renal denervation
Engagement With Recommended Developmental Follow-up and Supports Among Infants With Intrauterine Opioid Exposure
No full textObjective: Describe the engagement of opioid-exposed infants (OEI) with recommended developmental surveillance and supports in the first year of life.
Methods: We conducted a single-site retrospective cohort study of OEI delivered between 2016 and 2021, linking birth hospitalization, developmental follow-up (DFU) clinic, and early intervention (EI) records. Primary outcomes were attendance at DFU clinic and evaluation by EI. We used multivariable modified Poisson regression to examine how birthing parent-, infant-, and clinic-level factors are associated with service engagement.
Results: Of 256 OEI, 75% engaged in at least 1 developmental service. Referral and attendance rates at the DFU clinic were 69% and 33%, respectively. Ninety-three percent were referred to EI, 73% evaluated and 58% enrolled in services. EI evaluation was positively associated with prolonged infant hospitalization (adjusted risk ratio [aRR] 1.01; CI, 1.002-1.01) and exposure to antidepressants (aRR 1.23; CI, 1.02-1.49) and cocaine (aRR 1.28; CI, 1.09-1.50). Probability of attendance at DFU was higher for infants born to parents receiving care at an integrated perinatal substance use clinic (aRR 2.13; CI, 1.07-4.24) and exposed to antipsychotics (aRR 1.73; CI, 1.12-2.67), whereas those remaining in parental custody had lower probability of engagement (aRR 0.62; CI, 0.39-0.97).
Conclusion: Three-quarters of the OEI engaged in developmental surveillance services in the first year of life. Factors relating to disease severity, location of birthing parent care, birthing parent co-exposures, and parental custody were associated with engagement. Efforts to improve engagement in recommended follow-up should elicit the perspectives of caregivers to better understand the mechanisms that drive these differences.
Keywords: developmental follow-up; engagement; intrauterine opioid exposure