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Gender disparity in morbidity and mortality among patients with ST-elevation myocardial infarction due to spontaneous coronary artery dissection complicated by cardiogenic shock
No full textBackground: There is limited data on gender differences among patients with spontaneous coronary artery dissection (SCAD) who present as ST-elevation myocardial infarction (STEMI) and develop cardiogenic shock (CS).
Objectives: To describe outcomes of SCAD patients presenting with STEMI and CS and outline the differences between men and women.
Methods: We queried the US Nationwide Readmissions Database (NRD) from January 2016 to December 2020 to identify patients with SCAD presenting with STEMI who developed CS. We compared the characteristics, trends, and outcomes between men and women in this cohort.
Results: Out of 582,633 hospitalizations with STEMI, 0.2 % (1176 patients) had SCAD, of which 346 (29.4 %) had CS. There was no difference in median age between men and women (64 years (IQR 57-71) vs. 63 years (IQR 49-72), p = 0.181). Men had a higher prevalence of prior myocardial infarction (MI) (14.2 % vs. 6.2 %, p = 0.021). The overall mortality rate of SCAD patients with AMI-CS was 28.2 %, with no difference between men and women. Patients with SCAD who had CS and underwent CABG had a mortality of 20.3 %. ECMO was used in 6.1 % of SCAD patients presenting with STEMI and CS, with a survival rate of 49.9 %.
Conclusion: There were no differences in the baseline characteristics, rates of revascularization, or in-hospital mortality between men and women who had SCAD complicated by CS (SCAD-CS). Patients with SCAD-CS patients who underwent CABG had around 80 % in-hospital survival. CABG should be considered as a method of revascularization in this patient cohort.
Keywords: Cardiogenic shock; SCAD; STEMI
Veterans\u27 Lung Cancer Risk Conceptualizations versus Lung Cancer Screening Shared Decision-Making Conversations with Clinicians: A Qualitative Study
No full textBackground: The Veterans Health Administration (VA) recommends lung cancer screening (LCS), including shared decision making between clinicians and veteran patients. We sought to characterize 1) veteran conceptualization of lung cancer risk and 2) veteran and clinician accounts of shared decision-making discussions about LCS to assess whether they reflect veteran concerns.
Methods: We conducted qualitative interviews at 6 VA sites, with 48 clinicians and 34 veterans offered LCS in the previous 6 mo. We thematically analyzed transcripts, focusing on lung cancer risk perceptions, LCS decision making, and patient-clinician conversations.
Results: Three themes emerged. 1) Veterans\u27 lung cancer risk conceptualizations incorporated smoking, occupational hazards, and family history, whereas clinicians focused on smoking as the primary risk factor. 2) Veterans\u27 risk perceptions were influenced by symptoms, recency of exposures, and anecdotes about smoking, cancer, and lung disease, leading some veterans to believe other risk factors outweighed smoking in increasing lung cancer risk. 3) Both veterans and clinicians described LCS conversations centered on smoking, with little mention of other risks.
Limitations: Our findings may not reflect non-VA settings; for example, veterans may be more concerned about airborne hazards.
Conclusions: While airborne hazards strongly influenced veterans\u27 lung cancer risk conceptualizations, clinicians seldom addressed this risk factor during LCS shared decision making, instead focusing on smoking.
Implications: In 2022, the US Congress highlighted the link between military toxic exposures and lung cancer risk, requiring VA clinicians to discuss these exposures and conferring automatic VA benefits to exposed veterans with cancer. There is a time-sensitive need for tools to support VA clinicians in discussing military hazards as a lung cancer risk factor, which may result in more engaging, less stigmatizing LCS shared decision-making conversations.
Highlights: Veterans\u27 conceptualizations of their lung cancer risk were multifactorial and sometimes ranked exposure to occupational airborne hazards and family history above smoking in increasing lung cancer risk.However, patient-clinician lung cancer screening (LCS) conversations were typically brief and focused on smoking, which could stigmatize patients and failed to engage veterans in discussing what mattered most to them in thinking about their lung cancer risk.These findings are of heightened importance in light of the 2022 Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act, which requires VA clinicians to discuss toxic military exposures and their relationship to lung cancer and other health conditions.Tools that help clinicians assess and incorporate multiple risk factors into discussions about lung cancer may better address patients\u27 concerns and beliefs and lead to more engaging, less stigmatizing shared decision-making conversations about LCS.
Keywords: cancer risk; lung cancer screening; shared decision making; smoking cessation; veterans
Medication for Opioid Use Disorders (MOUD) Providers\u27 Experiences with Recovery Courts: Qualitative Study of Individual and Systemic Factors Impacting Interagency Collaboration
No full textBackground: Recovery courts mandate substance use disorder treatment as an alternative to prosecution or incarceration but lack internal resources to offer treatment. Hence, recovery courts must rely on community-based providers to ensure access to care. Interagency collaborations between recovery courts and providers of medications for opioid use disorders (MOUD) are often challenging. This qualitative study aimed to understand community-based MOUD providers\u27 perspectives on collaboration with recovery courts.
Methods: Semi-structured, hourlong interviews were conducted with 24 providers from 11 community agencies about their experiences and perceptions of working with recovery courts. Consolidated Framework for Implementation Research informed study design, coding, and analysis.
Results: At the individual-level domain, lack of knowledge about recovery courts and overall negative impressions of the criminal legal system were impediments to collaboration. Inner setting factors such as staffing shortages and provider roles in establishing therapeutic relationships limited active engagement in interagency collaboration. Outer setting domains such as communication barriers (eg, requirement of multiple release forms, lack of knowledge about who needed what information and when) and nonresponse from the courts were frequently referenced. Providers, however, also noted that direct experience with recovery court staff, especially in person, and recognition of mutual agency goals to ensure individuals receive proper care and remain in the community served as facilitators.
Discussion: While interagency collaboration is essential to ensuring that individuals in recovery courts can access MOUD, providers identify individual- and system-level barriers that impact collaboration with recovery courts. Results from providers mirror findings from recovery court staff that note communication barriers, distrust toward external agencies, and limited resources for active collaboration. Findings highlight areas where implementation strategies to improve collaboration can be targeted to ensure that individuals in recovery courts can access and remain in MOUD treatment.
Keywords: collaboration; community providers; drug courts; implementation science; interagency; medications for opioid use disorder; recovery courts
State-Level Structural Racism and Children\u27s Dental Care Access and Oral Health
No full textIntroduction: Black children in the United States have lower rates of dental visits and higher rates of poor oral health. However, few studies have examined the role of structural racism as a contributor to racial gaps in children\u27s oral health. This study assessed associations between state-level structural racism and oral health outcomes of children and the related Black-White disparities.
Methods: This repeated cross-sectional observational study examined children aged 1 to 17 y in the 2016 to 2021 National Survey of Children\u27s Health (NSCH). Three outcomes were examined: utilization (dentist visit in past 12 mo), any oral health problem (difficulty in past 12 mo with bleeding gums, cavities, or toothaches), and oral health (teeth in excellent or very good condition). A state-level index was constructed to measure Black-White structural racism composed of 5 dimensions (judicial, educational, economic, political, and neighborhood segregation) and linked to the NSCH. Estimated population-weighted logit regression models were used to assess associations between the outcomes and race and structural racism, adjusting for demographics and socioeconomic status.
Results: The dataset consisted of 98,423 Black (11%) or White (88%) children. Black children had relatively worse outcomes than White children did, with the largest difference observed for the children having teeth in excellent or very good condition (73% vs. 83%). State-level structural racism was not statistically significantly associated with a child receiving dental care, having any oral health problem, or having teeth in excellent or very good condition. US Black-White disparities in these outcomes were unchanged after adjustment for state-level structural racism.
Conclusions: Expanded efforts are needed to address US Black-White disparities in child oral health outcomes. State-level structural racism was not associated with these outcomes. Future research should explore whether findings change when examining these associations at a different geographic level and whether indices of structural racism should explicitly include items specific to health care access and child-specific institutional domains.
Knowledge transfer statement: Black children in this US study had relatively worse oral health and were less likely to have a dental visit than White children were. Structural racism did not explain these disparities, which suggests the need for further research to study mechanisms driving these disparities and how to address them. Policy makers should consider policies that expand where care is delivered, who delivers care, and increase dentists\u27 Medicaid participation, strategies identified previously for reducing disparities.
Keywords: child; dental care; health services accessibility; oral health; racism
Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023
No full textObjective: Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management.
Methods: Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.
Results: Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery.
Conclusions: There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.
Keywords: analgesia; comfort; enhanced recovery; multimodal analgesia; opioid; opioid-sparing; pain; perioperative care
Noninvasive respiratory support in the emergency department: Controversies and state-of-the-art recommendations
No full textAcute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies
Nursing News & Views - March 2024
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nursing_newsletters/1032/thumbnail.jp
Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults
No full textObjective: Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners.
Methods: Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups.
Results: The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients\u27 experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs.
Conclusions: Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners\u27 workflow, and legislative policies to ensure the success of MIH programs
Intensive longitudinal assessment following index trauma to predict development of PTSD using machine learning
No full textThere are significant challenges to identifying which individuals require intervention following exposure to trauma, and a need for strategies to identify and provide individuals at risk for developing PTSD with timely interventions. The present study seeks to identify a minimal set of trauma-related symptoms, assessed during the weeks following traumatic exposure, that can accurately predict PTSD. Participants were 2185 adults (Mean age=36.4 years; 64% women; 50% Black) presenting for emergency care following traumatic exposure. Participants received a \u27flash survey\u27 with 6-8 varying symptoms (from a pool of 26 trauma symptoms) several times per week for eight weeks following the trauma exposure (each symptom assessed ∼6 times). Features (mean, sd, last, worst, peak-end scores) from the repeatedly assessed symptoms were included as candidate variables in a CART machine learning analysis to develop a pragmatic predictive algorithm. PTSD (PCL-5 ≥38) was present for 669 (31%) participants at the 8-week follow-up. A classification tree with three splits, based on mean scores of nervousness, rehashing, and fatigue, predicted PTSD with an Area Under the Curve of 0.836. Findings suggest feasibility for a 3-item assessment protocol, delivered once per week, following traumatic exposure to assess and potentially facilitate follow-up care for those at risk.
Keywords: Emergency services; Machine learning; Mobile assessment; Posttraumatic stress disorder; Trauma
Coke in the Dope : The Underrecognized Complications of a Cocaine-Adulterated Fentanyl Supply
No full textThe opioid crisis, particularly the fourth wave involving fentanyl and stimulants, has been responsible for an alarming increase in overdose deaths in the United States. Although fentanyl contamination in cocaine has gained significant attention, the converse-cocaine-adulterated fentanyl-has been largely overlooked despite its health implications. The rise in concurrent cocaine and fentanyl overdose deaths could be attributed to various factors, from intentional polysubstance use to unintentional adulterations. Cocaine-related health issues may amplify the problem. Four potential pathways for the increased risk of overdose with cocaine-adulterated opioids include enhanced drug reinforcement, potential overdose risk with switching drug samples, altered metabolism of medications used for opioid use disorder, and increased myocardial demand juxtaposed with opioid-induced respiratory depression. With these risks, the importance of drug testing becomes paramount in the unregulated drug market. As polysubstance use overdoses surge, there is an urgent need to understand how drug supplies are changing in order to effectively identify appropriate harm reduction strategies. Specifically, further research is needed evaluating complications of low-level cocaine exposure with chronic/persistent opioid use. The hazards associated with cocaine-adulterated fentanyl emphasize the significance of understanding not only fentanyl\u27s presence in cocaine but also cocaine\u27s role in the fentanyl supply