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Association Between Area Deprivation Index and Narcotic Prescriptions, Wound Complications, and Reoperation Rates after Soft Tissue Hand and Wrist Surgery
No full textBACKGROUND: The area deprivation index (ADI) is an outcome metric that quantifies socioeconomic status by stratifying neighborhoods based on zip code. The purpose of this study was to investigate the effect of national ADI rank on the amount of narcotics prescribed, wound complications, and reoperations after routine hand or wrist surgery.
METHODS: We conducted a retrospective review of adult patients undergoing routine hand or wrist soft tissue surgery between 2013 and 2022. Patients were included if they underwent routine hand or wrist surgeries. Patients were excluded for having concomitant lacerations, penetrating injuries, or fractures. Multivariable logistic regression was performed to determine whether national ADI is associated with the amount of narcotics prescribed, the incidence of wound complications, and reoperation rates after routine hand and wrist procedures independent of covariates.
RESULTS: We included 1389 patients. The mean age was 55 years and 65 % were female. The average national ADI rank was 65.6. The largest ADI decile group that was categorized was in the 70-79 rank (consistent with a highly economically disadvantaged group), with the national median being set at 50. Wound complications occurred in 2.9 % of patients (n = 40) and reoperations occurred in 2.5 % of patients (n = 35). Multivariable regression determined that national ADI rank was not associated with a difference in the amount of narcotics prescribed (P = .141), wound complications (P = .599), or reoperation rates (P = .141).
CONCLUSIONS: National ADI rank was not associated with a significant difference in the amount of narcotics prescribed, wound complications, or reoperation rates
Design and methods of an adaptive trial to test comparative effectiveness of readmission reduction approaches following infection and sepsis hospitalizations (ACCOMPLISH)
No full textBACKGROUND: The months following hospitalization for sepsis and lower respiratory tract infection can often be very difficult for patients. Many will have subsequent clinical deterioration, which for some requires hospital readmission while, for others, transition to hospice care may be more appropriate. Unfortunately, there is a lack of high-quality evidence regarding how best to support patients in this period. Remote patient monitoring (RPM) technology can allow patients to remain at home yet be monitored for early signs of clinical deterioration. However, what should be monitored, and how any response should be coordinated, is unclear. We designed a pragmatic adaptive randomized clinical trial to determine the effect of four post-discharge RPM strategies comprising low vs. high intensity monitoring and standard versus enhanced care team response on 90-day hospital readmission rates.
METHODS: Adults admitted to the hospital with sepsis or lower respiratory tract infection (index admission) are recruited and randomized to usual care (structured telephonic support [STS]) or one of four post-discharge RPM care models in addition to STS. The primary outcome is home days, a composite endpoint of 90-day mortality and the number of days a patient spends at home within 90 days after discharge to home from the index admission. Hospital readmissions will be measured primarily by health insurance claims data. Secondary endpoints, such as functional status and health-related quality of life, will be measured at baseline and 90 days. An adaptive randomization process is run quarterly, improving patients\u27 chances to be randomized to the highest-performing intervention arms.
DISCUSSION: The study evaluates different post-discharge monitoring and workforce strategies to increase home days. With a large, representative sample and pragmatic adaptive study design, this research aims to deliver key insights into effective remote discharge monitoring technology and workforce deployment, benefiting patients, providers, and payers.
TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov (NCT04829188). https://clinicaltrials.gov/study/NCT04829188. Date of registration: January 4, 2021
An Exploratory Study of Sleep Quality After Lung Transplantation Using the Pittsburgh Sleep Quality Index
No full textIntroduction: Sleep is essential for maintaining optimal physical and mental health as it supports crucial functions such as cognition, immune system regulation, and overall well-being. A growing emphasis on the importance of sleep warrants an investigation of sleep quality after lung transplantation.
Research Question: What is the overall prevalence, nature, and severity of patient-reported disrupted sleep quality after lung transplantation using the Pittsburgh Sleep Quality Index (PSQI)? Design: This study employed a single-site, exploratory, cross-sectional descriptive design involving lung transplant recipients who completed an anonymous survey. Sleep quality was assessed using the PSQI scale. Additionally, participants provided self-reported data on demographic and transplant-related variables.
Results: The response rate was 38.4% (61/158) and 64% of the respondents (39/61) demonstrated PSQI \u3e5 with a mean PSQI score of 8.07 (SD = 4.5), suggestive of poor sleep quality. Lung transplant recipients reported difficulties across all components of sleep quality with more challenges in the categories of sleep duration, sleep latency, sleep efficiency, and the use of sleep medications.
Conclusion: The prevalence of poor subjective sleep quality among lung transplant recipients highlighted the importance of continued investigation into this phenomenon. Further research employing standardized measures, larger sample sizes, and longitudinal study designs is warranted to enhance understanding of poor sleep post-lung transplant. Such endeavors are crucial for informing the development of effective assessment strategies and interventions aimed at improving sleep outcomes in patients after lung transplantation
Centers with vascular surgery training programs are more likely to utilize vein mapping and autologous vein for infrainguinal bypass
No full textOBJECTIVE: The Society for Vascular Surgery (SVS) recommends preoperative vein mapping (PVM) and the use of autologous vein (AV) conduits when available for infrainguinal bypass (IIB). This study aims to evaluate the association between the presence of a vascular surgery (VS) training program at a medical center and the utilization of PVM and AV conduits in IIB procedures.
METHODS: Patients undergoing an elective IIB for peripheral artery disease (PAD) between 2016 and 2022 were identified in a prospective, statewide, multicenter observational registry. Hospital rates of PVM and AV utilization were calculated. Patients were then classified based on whether the medical center in which they were treated had an Accreditation Council for Graduate Medical Education (ACGME) certified VS training program or not. Both integrated vascular surgery residencies (0+5) and vascular surgery fellowships (5+2) were considered as VS training programs. Bayesian mixed effects logistic regressions were performed to study the independent association of VS training programs with the primary outcomes of PVM and AV utilization.
RESULTS: A total of 37 centers performing IIB were included, of which 24% (9/37) had a VS training program and 76% (28/37) did not. Hospital rates of PVM ranged from 10.2% to 81.7% with a median rate of 40.5% (IQR, 24.4%-61.9%), whereas that of AV utilization as an IIB conduit varied between 16.5% and 88.1% with a median rate of 43.8% (IQR, 33.3%-56.0%). A strong linear correlation between hospital rates of PVM and hospital rates of AV utilization was observed (R(2) = 0.956). A total of 5,951 patients met the inclusion criteria, of whom 36.9% (2,196/5,951) underwent IIB at centers with a VS training program and 63.1% (3,755/5,951) underwent IIB at centers without a VS training program. Patients treated at centers with a VS training program were less likely to undergo an IIB for claudication (47.0% vs 63.5%, p\u3c 0.001) and more likely to undergo preoperative ABI testing (68.9% vs 55.2%, p\u3c 0.001). Moreover, centers with a VS training program were more likely to perform PVM (57.7% vs 39.0%, p\u3c 0.001) and utilize an AV conduit (60.0% vs 45.3%, p\u3c 0.001) in IIB. On multivariate logistic regression analysis, centers with a VS training program were more than twice as likely to utilize PVM (OR 2.23, 95% CI 1.04-4.88) and nearly twice as likely to utilize AV as a conduit (OR 1.84, 95% CI 1.07-3.17) in patients undergoing IIB compared to centers without a VS training program.
CONCLUSION: The overall utilization of PVM and AV conduits in IIB remains below 50%, highlighting a significant concern in the national effort to improve PAD care. Centers with a VS training program demonstrate higher rates of PVM and AV utilization in IIB, reflecting greater adherence to SVS guidelines for the management of PAD. Future strategies and quality improvement initiatives should aim to enhance adherence to PAD guidelines within vascular surgery, regardless of practice setting
Socioeconomic disparities and MIBC survival outcome-An analysis of a statewide cohort
No full textPURPOSE: Muscle-invasive bladder cancer (MIBC) is an aggressive malignancy with limited survival improvements despite advancements in treatment. Socioeconomic disparities significantly affect patient outcomes, yet the Area Deprivation Index (ADI), a robust measure of socioeconomic status, has been underexplored in MIBC. This study evaluates the association between ADI and cancer-specific mortality (CSM) in MIBC.
MATERIALS AND METHODS: We retrospectively reviewed patients with MIBC (≥ T2; Any N; Any M) from the Michigan Department of Health and Human Services database (2004-2019). ADI scores were assigned based on residential census block groups and stratified into quartiles, with the 4th quartile (ADI 75-100) being the most deprived. Cumulative incidence functions compared CSM between quartiles, and competing-risk regression analysis assessed the association between ADI and CSM after adjusting for covariates.
RESULTS: Among 6120 patients (90% Non-Hispanic Whites; median age 73 [IQR 64-81]), most resided in metropolitan areas (80%) and were insured through Medicare (35%). Patients were distributed across ADI quartiles: 437 (1st), 1442 (2nd), 2171 (3rd), and 2070 (4th). At 10 years, CSM rates were 50%, 52%, 54%, and 55% for the 1st, 2nd, 3rd, and 4th quartiles, respectively (p = 0.01). Patients in the 3rd and 4th quartiles had 1.25 (HR 1.25, 95% CI 1.07-1.47, p = 0.016) and 1.30 (HR 1.30, 95% CI 1.11-1.54, p = 0.005) higher risks of CSM than those in the 1st quartile.
CONCLUSIONS: Higher ADI was associated with increased CSM in our cohort. Further studies are needed to explore potential causal mechanisms
Characterizing the HLA region\u27s genetic architecture through local heritability and correlation analyses across complex traits in diverse ancestries
No full textThe human leukocyte antigen (HLA) region is a critical genetic locus associated with diverse complex traits, yet its intricate genetic architecture poses significant challenges to elucidation. Leveraging recent advances in regional heritability estimation and extensive datasets from the Million Veteran Program (MVP), we conducted a comprehensive investigation of the HLA region\u27s genetic architecture. This involved heritability estimation and genetic correlation analyses within the HLA region across European Americans (EAs) and African Americans (AAs). Our analyses demonstrated that in EAs, the HLA region exhibited significantly greater local heritability than other genomic regions of comparable length for lipid metabolic traits (triglycerides [TG], total cholesterol [TC], high-density lipoprotein [HDL], low-density lipoprotein [LDL]), anthropometric measures (body mass index [BMI]), and suicide-related traits (suicidal ideation without suicide attempts [IDE] and suicidal thoughts and behaviors [SITB]) (false discovery rate [FDR]-adjusted empirical p-values \u3c 0.05). Notably, this enrichment was not observed in AAs. Genetic correlation analyses revealed disparities between local HLA and genome-wide findings. EAs exhibited 16 significant local HLA correlations and 32 genome-wide correlations. Conversely, AAs displayed more significant local genetic correlations within the HLA region (14 pairs) than genome-wide (3 pairs), with two pairs (IDE-SITB, LDL-TC) concordantly significant. These findings underscore the HLA region\u27s substantial contribution to the variance of these lipid metabolic traits, BMI, and suicide-related traits. Further investigation into the genetic mechanisms by which HLA-mediated pathways influence these phenotypes is crucial for elucidating the complex role of this region, particularly concerning lipid metabolism and suicidal behaviors
Opioid use disorder medications among youth in primary care: Subgroup analysis of the PROUD trial
No full textOBJECTIVE: Medications for opioid use disorder (OUD) are under-utilized among adolescents and young adults ( youth ). Offering buprenorphine or naltrexone in primary care settings may reduce barriers to their use among youth. We conducted a secondary, patient-level analysis of the PROUD cluster-randomized clinical trial, which tested the implementation of a nurse care management intervention to support prescribing OUD medications.
METHODS: 12 primary care clinics from 6 health systems were randomized in 2018 and patient-level data was collected from 2 years before to 2 years after randomization. The primary outcome was any OUD medication treatment (i.e., buprenorphine or extended-release injectable naltrexone) during the post-randomization period for youth ages 16-25 years.
RESULTS: A total of 20,253 youth ages 16-25 years were seen in intervention and 26,562 in usual care clinics during the study period. Comparing patients by clinic arm, we did not detect a statistically significant difference in the odds of receiving OUD medication treatment after randomization (odds ratio 1.75, 95% CI 0.63-4.89). Among the small number of patients (n=67) who received OUD medication after randomization, median treatment days were 81.5 days (IQR 30-177) and 64 days (IQR 24-206) in intervention or usual care clinics, respectively.
CONCLUSIONS: We did not find evidence that implementing a primary care nurse care management model meaningfully increased OUD medication treatment among youth. In this special population, youth-centered approaches may be needed to promote prescribing and overcome known barriers to care, such as provider and patient hesitancy to use OUD medications
Development and Piloting of a Scalable Training for Peer Recovery Specialists in an Evidence-Based Substance Use Intervention: Preliminary Implementation Outcomes.
No full textIndividuals from minoritized and under-resourced communities have significantly less access to specialized services from substance use disorder. Peer recovery specialists (PRSs) show promise for increasing access to services, especially in low-resource settings, but have not historically been trained to deliver evidence-based interventions (EBIs). While behavioral activation (BA) has shown promise as a PRS-delivered EBI, few studies have examined broader training efforts that may inform the scale-up of this model. This study describes the co-development (including PRSs and community-based treatment providers) and dissemination of a BA training for PRSs. The initial training was piloted with five PRSs, who provided qualitative feedback on training content and delivery. The revised training was then delivered to 168 PRSs. Post-training, participants completed implementation outcome measures assessing feasibility, acceptability, and appropriateness. A follow-up survey was sent within six months to assess continued use and perceptions of BA. Qualitative feedback identified BA as feasible for PRS delivery and appropriate for the PRS role, and identified ongoing supervision and experiential learning as key needs for PRS training. PRSs who received the revised training found it to be feasible, appropriate and acceptable. Follow-up surveys suggest PRSs continued to use BA skills and found it was a good fit to their role and feasible for their work situation. PRS-delivery of EBIs has the potential to increase access to treatment for individuals from low-resource communities. With appropriate modifications for the unique needs of this workforce, PRSs can be trained on a large-scale to deliver BA
Symmetrical Drug-Related Intertriginous and Flexural Exanthema in Setting of GLP-1 Agonist: A Case Report
No full textSubcorneal pustular dermatosis masquerading as eczematous dermatitis: a case report and mechanistic review
No full textThis case describes a woman with a decades-long history of misdiagnosed eczematous dermatitis ultimately identified as subcorneal pustular dermatosis (SPD), a rare neutrophilic dermatosis. Initially treated unsuccessfully for presumed atopic dermatitis and prurigo nodularis with various immunomodulatory agents, including dupilumab and Janus kinase (JAK) inhibitors, the correct diagnosis was made only after the appearance of characteristic flaccid pustules in intertriginous areas. Histopathological analysis confirmed SPD, and following intolerance to initial treatment with dapsone, the patient experienced a dramatic and sustained clinical improvement with infliximab. This case highlights the diagnostic challenges posed by atypical presentations of SPD and supports the use of tumour necrosis factor-alpha (TNFα) inhibitors as a highly effective treatment option