Medications for alcohol-use disorder and follow-up after hospitalization for alcohol withdrawal: A multicenter study.

BACKGROUND: Alcohol withdrawal is a common reason for admission to acute care hospitals. Prescription of medications for alcohol-use disorder (AUD) and close outpatient follow-up are commonly recommended, but few studies report their effects on postdischarge outcomes. OBJECTIVES: The objective of this study is to evaluate the effects of medications for AUD and follow-up appointments on readmission and abstinence. METHODS: This retrospective cohort study evaluated veterans admitted for alcohol withdrawal to medical services at 19 Veteran Health Administration hospitals between October 1, 2018 and September 30, 2019. Factors associated with all-cause 30-day readmission and 6-month abstinence were examined using logistic regression. RESULTS: Of the 594 patients included in this study, 296 (50.7%) were prescribed medications for AUD at discharge and 459 (78.5%) were discharged with follow-up appointments, including 251 (42.8%) with a substance-use clinic appointment, 191 (32.9%) with a substance-use program appointment, and 73 (12.5%) discharged to a residential program. All-cause 30-day readmission occurred for 150 patients (25.5%) and 103 (17.8%) remained abstinent at 6 months. Medications for AUD and outpatient discharge appointments were not associated with readmission or abstinence. Discharge to residential treatment program was associated with reduced 30-day readmission (adjusted odds ratio [AOR]: 0.39, 95% confidence interval [95% CI]: 0.18-0.82) and improved abstinence (AOR: 2.50, 95% CI: 1.33-4.73). CONCLUSIONS: Readmission and return to heavy drinking are common for patients discharged for alcohol withdrawal. Medications for AUD were not associated with improved outcomes. The only intervention at the time of discharge that improved outcomes was discharge to residential treatment program, which was associated with decreased readmission and improved abstinence.

Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study.

OBJECTIVES: Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM). METHODS: We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined. RESULTS: Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal. CONCLUSIONS: Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations.

Primary Care Considerations for Elderly U.S. Veterans of World War II and the Korean War: A Narrative Review.

Many of the United States' more than 18 million veterans obtain healthcare through the Department of Veterans Affairs' (VA) Veterans Health Administration system; however, recent legislative changes have expanded veterans' access to non-VA care in their communities, particularly for those who do not live near VA medical centers. Veterans are seen by physicians in outpatient practice across the United States and are admitted to non-VA hospitals; this is particularly salient for older veterans, who may require a more frequent and high level of care. We present a review of characteristics of U.S. veterans from two conflicts: World War II (WWII) and the Korean War. While non-VA clinicians are well equipped to provide care for patients of all different ages, veterans of armed conflicts have a unique constellation of exposures and cultural considerations that must be accounted for when providing them care. In this review, we describe characteristics of the generations of American veterans who served in WWII and the Korean War conflicts in a brief historical context. We then note conflict-specific exposures and potential long-term sequelae to watch for during physical examinations and to monitor thereafter, age-specific health and emotional concerns, and best practices for providing care to this cohort of veterans.

Cannabis-Induced Acute Encephalopathy in a 94-Year-Old Woman Due to Family Administration of Cannabidiol (CBD) Products: A Case Report.

In the United States, cannabis use is rising, including among older adults, as is unintentional ingestion. We describe the case of a 94-year-old woman admitted with altered mental status, diarrhea, and hallucinations. She lived with her family, who had noticed recent confusion with weakness, poor oral intake, and loose bowel movements. In the emergency room, her vital signs revealed mild tachycardia and hypotension. She was lethargic, disoriented, confused, and anxious but could answer simple questions. The attending hospitalist administered the Mini-Cog dementia screening and found that the patient was oriented to herself only and was unable to perform word recall tests or complete a clock drawing. The rest of her physical exam was within normal limits for her age. Despite a workup including urine culture, chest X-ray, and computed tomography scan of her head, no organic source for her mental change was found. After five days of admission, a close relative confessed that they had given the patient cannabis oil (marketed as "pure CBD," i.e., cannabidiol, a nonpsychoactive cannabis derivative widely touted as a remedy for pain, anxiety, and anorexia) in the form of edible brownies to help her with her persistent back pain and poor appetite. We performed a urine drug screen for tetrahydrocannabinol (THC), the psychoactive component of cannabis, which verified cannabis use, as well as exposure to THC. The patient recovered to baseline with supportive care. Currently, there is no governing body or framework for the regulation of cannabis products in the United States. Nonprescription CBD products are not regulated by the US Food and Drug Administration, and these products are not tested for safety, efficacy, or quality. Some producers voluntarily conduct such testing, but there is no regulatory oversight, and consumers may be unaware of the need for testing and/or which testing bodies are credible. Given the rapidly increasing proportion of older adults who are cannabis users, physicians should inquire about outpatient use of cannabis in general and CBD in particular during discussions with patients, even the most elderly.

An Epidemic Supplanted by a Pandemic: Vaping-Related Illness and COVID-19.

Before the coronavirus disease 2019 (COVID-19) pandemic, vaping-related illness was the prevailing public health concern. The incidence of vaping-related illnesses-mainly e-cigarette, or vaping, product use-associated lung injury (EVALI)-went from a peak in September 2019 to a low in February 2020, and the Centers for Disease Control and Prevention decided to discontinue the collection of EVALI case reports. Despite the decrease in EVALI with the arrival of COVID-19, EVALI should still be considered a differential diagnosis for people with COVID-19 for reasons outlined in this review. This narrative review describes vaping devices, summarizes the adverse health effects of vaping on the lungs and other systems, considers the potential interplay between vaping and COVID-19, and highlights gaps in knowledge about vaping that warrant further research.

Using Stroke Order Sets to Improve Compliance With Quality Measures for Ischemic Stroke Admissions.

Creation of electronic health record order sets may improve adherence to The Joint Commission National Quality Measures for care of veterans with ischemic stroke.

Frequencies of mtDNA mutations in primary tissues of colorectal adenopolyps.

To investigate the potential role of mtDNA alterations during the onset of colorectal cancer, the occurrence of mtDNA variants in colorectal adenomatous (Tubular, Tubulovillous, and Villous) polyps, were studied. High resolution endonucleases and PCR-based sequence were applied to examine mtDNA variants in the ND and ATPase genes of 64 primary tissues of colorectal adeno-polyps and their matched normal controls. Forty-two variants were observed and 57% (24/42) were not previously reported in the MITODAT reference. Fifty-eight percent of these variants were germline and homoplasmic transitions. The distribution of observed mtDNA variants includes: 31% (13/42) tubular, 52% (22/42) tubulovillous, 45% (19/42) villous, and 45% (19/42) cancer (including FAP and JVP). Notably, an unreported germline variant in the ATPase 8 gene at nucleotide position (np) G8573A was observed in tubulovillous adenomas tissues. The results suggest that some specific mtDNA variants may serve as a potential biomarker for colorectal adenomatous polyps.

Analysis of mtDNA sequence variants in colorectal adenomatous polyps.

Colorectal tumors mostly arise from sporadic adenomatous polyps. Polyps are defined as a mass of cells that protrudes into the lumen of the colon. Adenomatous polyps are benign neoplasms that, by definition display some characteristics of dysplasia. It has been shown that polyps were benign tumors which may undergo malignant transformation. Adenomatous polyps have been classified into three histologic types; tubular, tubulovillous, and villous with increasing malignant potential. The ability to differentially diagnose these colorectal adenomatous polyps is important for therapeutic intervention. To date, little efforts have been directed to identifying genetic changes involved in adenomatous polyps. This study was designed to examine the relevance of mitochondrial genome alterations in the three adenomatous polyps. Using high resolution restriction endonucleases and PCR-based sequencing, fifty-seven primary fresh frozen tissues of adenomatous polyps (37 tumors and 20 matched surrounding normal tissues) obtained from the southern regional Cooperative Human Tissue Network (CHTN) and Grady Memorial Hospital at Atlanta were screened with three mtDNA regional primer pairs that spanned 5.9 kbp. Results from our data analyses revealed the presence of forty-four variants in some of these mitochondrial genes that the primers spanned; COX I, II, III, ATP 6, 8, CYT b, ND 5, 6 and tRNAs. Based on the MITODAT database as a sequence reference, 25 of the 44 (57%) variants observed were unreported. Notably, a heteroplasmic variant C8515G/T in the MT-ATP 8 gene and a germline variant 8327delA in the tRNAlys was observed in all the tissue samples of the three adenomatous polyps in comparison to the referenced database sequence. A germline variant G9055A in the MT-ATP 6 gene had a frequency of 100% (17/17) in tubular and 57% (13/23) in villous adenomas; no corresponding variant was in tubulovillous adenomas. Furthermore, A9006G variant at MT-ATP 6 gene was observed at frequency of 57% (13/23) in villous adenomas only. Interestingly, variants A9006G and G9055A were absent in the villous tissue samples that were clinicopathological designated as "polyvillous adenomas". Our current data provide a basis for continued investigation of certain mtDNA variants as predictors of the three adenomatous polyps in a larger number of clinicopathological specimens.