Procedural Fairness in Physician-Patient Communication: A Predictor of Health Outcomes in a Cohort of Adults with Overweight or Obesity.

BACKGROUND: This study aimed to explore whether patients' perception of procedural fairness in physicians' communication was associated with willingness to follow doctor's recommendations, self-efficacy beliefs, dietary behaviors, and body mass index. METHODS: This was a secondary analysis of baseline data from 489 primary care patients with a BMI ≥ 25 kg/m2 (43.6% Black, 40.7% Hispanic/Latino, 55.8% female, mean age = 50 years), who enrolled in a weight management study in two New York City healthcare institutions. We conducted ordinary least squares path analyses with bootstrapping to explore direct and indirect associations among procedural fairness, willingness to follow recommendations, self-efficacy, dietary behaviors, and body mass index, while controlling for age and gender. RESULTS: Serial, multiple mediator models indicated that higher procedural fairness was associated with an increased willingness to follow recommendations which, in turn, was associated with healthier dietary behaviors and a lower BMI (indirect effect = - .02, SE = .01; 95% CI [- .04 to - .01]). Additionally, higher procedural fairness was associated with elevated dietary self-efficacy, which was, in turn, was associated with healthier dietary behaviors and lower BMI (indirect effect = - .01, SE = .003; 95% CI [- .02 to - .002]). CONCLUSIONS: These findings highlight the importance of incorporating procedural fairness in physician-patient communication concerning weight management in diverse primary care patients.

Does exercise training improve exercise tolerance, quality of life, and echocardiographic parameters in patients with heart failure with preserved ejection fraction? A systematic review and meta-analysis of randomized controlled trials.

Patients with heart failure with preserved ejection fraction (HFpEF) often experience dyspnea, decreased exercise tolerance, and decreased quality of life (QOL). Exercise training is a promising non-pharmacological treatment, with some improvement in exercise tolerance and QOL in HFpEF patients in randomized controlled trials (RCTs). We conducted a systematic review and meta-analysis of RCTs examining the effect of exercise therapy on exercise tolerance, QOL, and echocardiographic parameters in patients with HFpEF. Article database search of PubMed, Embase, and Cochrane Central Register of Controlled Trials identified 15 publications representing 579 unique patients. Results are presented as weighted mean difference (WMD) with 95% confidence intervals (CI). Exercise training (compared to control) demonstrated a significant improvement in exercise tolerance as measured by peak absolute VO2 (WMD [95% CI] = 164.67 [65.54, 263.79] mL/min), peak relative VO2 (WMD [95% CI] = 1.85 [0.98, 2.73] mL/min/kg), workload (WMD [95% CI] = 12.92 [4.67, 21.17] W), exercise time (WMD [95% CI] = 2.05 [1.57, 2.53] min), anaerobic threshold (WMD [95% CI] = 170.31 [35.40, 305.22] mL/min/kg), and 6-min walk test distance (WMD [95% CI] = 32.77 [20.72, 44.83] m); in QOL as measured by Short Form (SF-36) physical functioning domain (WMD [95% CI] = 9.95 [2.85, 17.05]) and SF-36 vitality domain (WMD [95% CI] = 6.24 [0.15, 12.34]); and in the echocardiographic measure of LVESD (WMD [95% CI] = - 0.16 [- 0.28, - 0.04] cm). In conclusion, we found after systematic review and meta-analysis of RCTs that exercise therapy improves exercise tolerance and physical-related quality of life measures.

Dynamic Interpersonal Therapy for U.S. Veterans in a Primary Care Setting.

OBJECTIVE: Brief dynamic interpersonal therapy (DIT) is an evidence-based psychodynamic intervention for depression offered by the U.K. National Health Service and previously studied in the context of a U.S. Department of Veterans Affairs medical center. This study assessed the clinical value of DIT in primary care for veterans with general medical conditions. METHODS: The authors examined outcome data of veterans (N=30; all but one had ≥1 comorbid general medical conditions) referred to DIT from primary care. RESULTS: Veterans who began treatment with clinically elevated depression or anxiety experienced a 42% reduction in symptom severity, as measured by the nine-item Patient Health Questionnaire or by the seven-item Generalized Anxiety Disorder questionnaire, respectively, representing large effect sizes. CONCLUSIONS: Significant decreases in depression and anxiety symptoms suggest the utility of DIT for veterans with comorbid general medical conditions. DIT's dynamically informed framework may improve patients' help seeking, which is relevant for patients experiencing comorbid medical conditions.

Transoral robotic surgery adoption and safety in treatment of oropharyngeal cancers.

BACKGROUND: Transoral robotic surgery (TORS) was approved by the Food and Drug Administration in 2009 for the treatment of oropharyngeal cancers (oropharyngeal squamous cell carcinoma [OPSCC]). This study investigated the adoption and safety of TORS. METHODS: All patients who underwent TORS for OPSCC in the National Cancer Data Base from 2010 to 2016 were selected. Trends in the positive margin rate (PMR), 30-day unplanned readmission, and early postoperative mortality were evaluated. Outcomes after TORS, nonrobotic surgery (NRS), and nonsurgical treatment were compared with matched-pair survival analyses. RESULTS: From 2010 to 2016, among 73,661 patients with OPSCC, 50,643 were treated nonsurgically, 18,024 were treated with NRS, and 4994 were treated with TORS. TORS utilization increased every year from 2010 (n = 363; 4.2%) to 2016 (n = 994; 8.3%). The TORS PMR for base of tongue malignancies decreased significantly over the study period (21.6% in 2010-2011 vs 15.8% in 2015-2016; P = .03). The TORS PMR at high-volume centers (≥10 cases per year; 11.2%) was almost half that of low-volume centers (<10 cases per year; 19.3%; P < .001). The rates of 30-day unplanned readmission (4.1%) and 30-day postoperative mortality (1.0%) after TORS were low and did not vary over time. High-volume TORS centers had significantly lower rates of 30-day postoperative mortality than low-volume centers (0.5% vs 1.5%; P = .006). In matched-pair analyses controlling for clinicopathologic cofactors, 30-, 60-, and 90-day posttreatment mortality did not vary among patients with OPSCC treated with TORS, NRS, or nonsurgical treatment. CONCLUSIONS: TORS has become widely adopted and remains safe across the country with a very low risk of severe complications comparable to the risk with NRS. Although safety is excellent nationally, high-volume TORS centers have superior outcomes with lower rates of positive margins and early postoperative mortality.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial.

BACKGROUND: Financial distress is a barrier to cessation among low-income smokers. OBJECTIVE: To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers. DESIGN: Randomized waitlist control trial conducted from 2017 to 2019. PARTICIPANTS: Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community. INTERVENTION: The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period. MAIN MEASURES: Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months. KEY RESULTS: At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (ß, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (ß, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (ß, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (ß, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (ß, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (ß, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05). CONCLUSIONS: Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03187730.

Effects of hippocampal interictal discharge timing, duration, and spatial extent on list learning.

Interictal epileptiform discharges (IEDs) can impair memory. The properties of IEDs most detrimental to memory, however, are undefined. We studied the impact of temporal and spatial characteristics of IEDs on list learning. Subjects completed a memory task during intracranial EEG recordings including hippocampal depth and temporal neocortical subdural electrodes. Subjects viewed a series of objects, and after a distracting task, recalled the objects from the list. The impacts of IED presence, duration, and propagation to neocortex during encoding of individual stimuli were assessed. The effects of IED total number and duration during maintenance and recall periods on delayed recall performance were also determined. The influence of IEDs during recall was further investigated by comparing the likelihood of IEDs preceding correctly recalled items vs. periods of no verbal response. Across 6 subjects, we analyzed 28 hippocampal and 139 lateral temporal contacts. Recall performance was poor, with a median of 17.2% correct responses (range 10.4-21.9%). Interictal epileptiform discharges during encoding, maintenance, and recall did not significantly impact task performance, and there was no significant difference between the likelihood of IEDs during correct recall vs. periods of no response. No significant effects of discharge duration during encoding, maintenance, or recall were observed. Interictal epileptiform discharges with spread to lateral temporal cortex during encoding did not adversely impact recall. A post hoc analysis refining model assumptions indicated a negative impact of IED count during the maintenance period, but otherwise confirmed the above results. Our findings suggest no major effect of hippocampal IEDs on list learning, but study limitations, such as baseline hippocampal dysfunction, should be considered. The impact of IEDs during the maintenance period may be a focus of future research.

Racial and weight discrimination associations with pain intensity and pain interference in an ethnically diverse sample of adults with obesity: a baseline analysis of the clustered randomized-controlled clinical trial the goals for eating and moving (GEM) study.

BACKGROUND: Everyday experiences with racial (RD) and weight discrimination (WD) are risk factors for chronic pain in ethnically diverse adults with obesity. However, the individual or combined effects of RD and WD on pain in adults with obesity is not well understood. There are gender differences and sexual dimorphisms in nociception and pain, but the effect of gender on relationships between RD, WD, and pain outcomes in ethnically diverse adults with obesity is unclear. Thus, the purposes of this study were to: 1) examine whether RD and WD are associated with pain intensity and interference, and 2) explore gender as a moderator of the associations between RD, WD, and pain. METHODS: This is a baseline data analysis from a randomized, controlled clinical trial of a lifestyle weight-management intervention. Eligible participants were English or Spanish-speaking (ages 18-69 years) and had either a body mass index of ≥30 kg/m2 or ≥ 25 kg/m2 with weight-related comorbidity. RD and WD were measured using questions derived from the Experiences of Discrimination questionnaire (EOD). Pain interference and intensity were measured using the PROMIS 29 adult profile V2.1. Linear regression models were performed to determine the associations between WD, RD, gender, and pain outcomes. RESULTS: Participants (n = 483) reported mild pain interference (T-score: 52.65 ± 10.29) and moderate pain intensity (4.23 ± 3.15). RD was more strongly associated with pain interference in women (b = .47, SE = .08, p < 001), compared to men (b = .14, SE = .07, p = .06). Also, there were no significant interaction effects between RD and gender on pain intensity, or between WD and gender on pain interference or pain intensity. CONCLUSIONS: Pain is highly prevalent in adults with obesity, and is impacted by the frequencies of experiences with RD and WD. Further, discrimination against adults with obesity and chronic pain could exacerbate existing racial disparities in pain and weight management. Asking ethnically diverse adults with obesity about their pain and their experiences of RD and WD could help clinicians make culturally informed assessment and intervention decisions that address barriers to pain relief and weight loss. TRIAL REGISTRATION: NCT03006328.

Effects of carbonation of liquids on penetration-aspiration and residue management.

OBJECTIVE: Carbonation as a sensory enhancement strategy for prevention of aspiration of thin liquids has not been thoroughly studied. The aim of our study was to examine the effect of carbonation on penetration-aspiration and pharyngeal residue in dysphagia patients using Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) and to identify parameters associated with a response to carbonation. METHODS: A cross-sectional study of patients undergoing FEES in a dysphagia clinic. Patients were offered 100 cc of dyed water. Penetration-aspiration was scored using the penetration-aspiration scale (PAS). Residue was scored using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). Patients with a PAS ≥ 2 for water were subsequently offered 100 cc of carbonated water. PAS, YPR-SRS and residue clearance were compared between thin and carbonated liquids. Multivariate logistic regression analysis was used to identify predictors for good response to carbonation. RESULTS: 84 patients were enrolled, 77.4% males, with diverse dysphagia etiologies (58.3% neurogenic, 11.9% radiation-induced, 23.8% deconditioning-induced, and 6% neck surgery induced). Median PAS was 7 (IQR 4-8) for thin liquids and 4.5 (IQR 2-8) for carbonated liquids (P = 0.0001). YPR-SRS was reduced for carbonated compared to thin liquids in the vallecula (1.58 ± 0.83 vs 1.76 ± 0.93, P = 0.001) and piriform sinuses (1.5 ± 0.87 vs 1.67 ± 0.9, P = 0.002). 31 patients had improvement in PAS with carbonation. Deconditioning as a dysphagia etiology was found to predict good response to carbonation on multivariate logistic regression analysis. CONCLUSION: Carbonation may prevent aspiration and improve residue management for some patients with dysphagia for liquids. LEVEL OF EVIDENCE: IV.

Predicting adults likely to develop heart failure using readily available clinical information: An analysis of heart failure incidence using the NHEFS.

BACKGROUND: Heart failure is a heavy burden on the health care system in the United States. Once heart failure develops, the quality of life and longevity are dramatically affected. As such, its prevention is critical for the well-being of at risk patients. We evaluated the predictive ability of readily available clinical information to identify those likely to develop heart failure. METHODS: We used a classification and regression tree (CART) model to determine the top predictors for heart failure incidence using the NHANES Epidemiologic Follow-up Study (NHEFS). The identified predictors were hypertension, diabetes, obesity, and myocardial infarction (MI). We evaluated the relationship between these variables and incident heart failure by the product-limit method and Cox models. All analyses incorporated the complex sample design to provide population estimates. RESULTS: We analyzed data from 14,407 adults in the NHEFS. Participants with diabetes, MI, hypertension, or obesity had a higher incidence of heart failure than those without risk factors, with diabetes and MI being the most potent predictors. Individuals with multiple risk factors had a higher incidence of heart failure as well as a higher hazard ratio than those with just one risk factor. Combinations that included diabetes and MI had the highest incidence rates of heart failure per 1000 person years and the highest hazard ratios for incident heart failure. CONCLUSIONS: Having diabetes, MI, hypertension or obesity significantly increased the risk for incident heart failure, especially combinations including diabetes and MI. This suggests that individuals with these conditions, singly or in combination, should be prioritized in efforts to predict and prevent heart failure incidence.

Does Smoking Intensity Predict Cessation Rates? A Study of Light-Intermittent, Light-Daily, and Heavy Smokers Enrolled in Two Telephone-Based Counseling Interventions.

INTRODUCTION: Though many interventions have been shown to be effective in helping smokers quit, outcomes may differ between light and heavy smokers. We identified differences in baseline characteristics and post-intervention cessation rates among smoker groups at two safety-net hospitals. METHODS: We retrospectively analyzed cessation rates in 1604 patients randomized to either a quitline referral (1-2 telephone counseling sessions) or intensive counseling program (seven telephone sessions). Participants were stratified into light-intermittent (smoked on ≤24 of last 30 days), light-daily (smoked on >24/30 days, 1-9 cigarettes per day [CPD]), or heavy smokers (smoked on >24/30 days, ≥10 CPD). We compared baseline characteristics between smoker types using chi-squared tests, then identified predictors of 30-day abstinence using a multivariable model. RESULTS: Compared with light-daily and light-intermittent smokers, heavy smokers were more likely to be white, male, concomitant e-cigarette users, to have high-risk alcohol use, to have used quitting aids previously, to have current or lifetime substance use (excluding cannabis), and have lower confidence in quitting. However, in multivariable analysis, smoker type was not significantly associated with cessation. The statistically significant predictors of cessation at 6 months were higher confidence in quitting and enrollment in the intensive counseling intervention. CONCLUSIONS: Smoker type (light-intermittent, light-daily, or heavy) does not independently predict success in a cessation program. However, smoker type is strongly associated with patients' confidence in quitting, which may be one predictor of cessation. IMPLICATIONS: This study of two safety-net hospitals emphasizes that the number of cigarettes smoked per day does not independently predict smoking cessation. Additionally, heavy smokers are at highest risk for the detrimental health effects of tobacco, yet have lower confidence and motivation to quit. Confidence in quitting may be one factor that affects cessation rates; however, further study is needed to identify which other attributes predict cessation. These findings suggest that smoker type may still be a useful proxy for predicting cessation and that interventions specifically designed for and validated in heavy smokers are needed to better aid these individuals.

The Influence of Metabolic Syndrome in Predicting Mortality Risk Among US Adults: Importance of Metabolic Syndrome Even in Adults With Normal Weight.

INTRODUCTION: Although metabolic syndrome (MetS) is less prevalent among normal-weight adults than among overweight and obese adults, it does occur. The objective of our study was to examine how mortality risks differed in weight categories stratified by presence/absence of MetS. METHODS: We linked data for US adults responding to the National Health and Nutrition Examination Survey from 1999 through 2010 to data released from the National Death Index up to 2011. We grouped data according to categories of body mass index (normal [18.5 to <25.0 kg/m2], overweight [25.0 to <30.0 kg/m2], and obese [≥30.0 kg/m2]) and presence/absence of MetS. After conducting unadjusted analyses, we used Cox proportional hazards models to evaluate mortality risk as multivariable hazard ratios among obesity-MetS categories while controlling for selected covariates. RESULTS: The analysis included 12,047 adults. The prevalence of MetS was 61.6% in the obese group, 33.2% in the overweight group, and 8.6% in the normal-weight group. The multivariate adjusted hazard ratio (95% confidence interval) for mortality among the obesity-MetS groups, compared with the normal-weight-no-MetS group, were as follows: normal-weight-MetS (1.70 [1.16-2.51]), overweight-no-MetS (0.99 [0.77-1.28]), overweight-MetS (1.10 [0.85-1.42]), obese-no-MetS (1.08 [0.76-1.54]), and obese-MetS (1.30 [1.07-1.60]); differences were significant only for the normal-weight-MetS group and obese-MetS group. CONCLUSION: MetS is a risk factor for mortality among normal-weight and obese adults. In our study, normal-weight adults with MetS had the highest mortality among the 6 groups studied, suggesting that interventions should also focus on MetS patients with normal weight.

Disparities in hospital smoking cessation treatment by immigrant status.

Despite the efficacy of nicotine replacement therapy (NRT) in promoting smoking cessation, no studies have been done to evaluate NRT prescribing rates among immigrants, a vulnerable minority population in the United States. The aim of this study is to explore for differences in NRT prescribing behavior by immigrant status. Participants were enrolled in a smoking cessation trial for hospitalized patients between July 2011 and April 2014 at two NYC hospitals. For this analysis, we used baseline data from patient surveys and electronic medical-record reviews to examine associations between immigrant status and prescription of NRT in-hospital and on discharge, as well as acceptance of NRT in-hospital. We included age, gender, education, health literacy, race, ethnicity, English language ability, inpatient service, and site insurance in the models as potential confounders. Our study population included 1,608 participants, of whom 21% were not born in the United States. Bivariate analysis found that nonimmigrants were more likely than immigrants to be prescribed NRT in the hospital (46.1% vs. 35.7%, p = .0006) and similarly on discharge (19.4% vs. 15.3%, p = .09). Both groups were equally likely to accept NRT in-hospital when prescribed. On multivariable analysis, being an immigrant (OR 0.65), Black race (OR 0.52), and Hispanic ethnicity (OR 0.63) were associated with lower likelihood of being prescribed NRT in-hospital. Multivariable analysis for provision of NRT prescription at discharge showed no significant difference between immigrants and nonimmigrants. These findings show differences in in-hospital smoking cessation treatment between immigrants and nonimmigrants.

The Effect of Hearing Aid Bandwidth and Configuration of Hearing Loss on Bimodal Speech Recognition in Cochlear Implant Users.

OBJECTIVES: (1) To determine the effect of hearing aid (HA) bandwidth on bimodal speech perception in a group of unilateral cochlear implant (CI) patients with diverse degrees and configurations of hearing loss in the nonimplanted ear, (2) to determine whether there are demographic and audiometric characteristics that would help to determine the appropriate HA bandwidth for a bimodal patient. DESIGN: Participants were 33 experienced bimodal device users with postlingual hearing loss. Twenty three of them had better speech perception with the CI than the HA (CI>HA group) and 10 had better speech perception with the HA than the CI (HA>CI group). Word recognition in sentences (AzBio sentences at +10 dB signal to noise ratio presented at 0° azimuth) and in isolation [CNC (consonant-nucleus-consonant) words] was measured in unimodal conditions [CI alone or HAWB, which indicates HA alone in the wideband (WB) condition] and in bimodal conditions (BMWB, BM2k, BM1k, and BM500) as the bandwidth of an actual HA was reduced from WB to 2 kHz, 1 kHz, and 500 Hz. Linear mixed-effect modeling was used to quantify the relationship between speech recognition and listening condition and to assess how audiometric or demographic covariates might influence this relationship in each group. RESULTS: For the CI>HA group, AzBio scores were significantly higher (on average) in all bimodal conditions than in the best unimodal condition (CI alone) and were highest at the BMWB condition. For CNC scores, on the other hand, there was no significant improvement over the CI-alone condition in any of the bimodal conditions. The opposite pattern was observed in the HA>CI group. CNC word scores were significantly higher in the BM2k and BMWB conditions than in the best unimodal condition (HAWB), but none of the bimodal conditions were significantly better than the best unimodal condition for AzBio sentences (and some of the restricted bandwidth conditions were actually worse). Demographic covariates did not interact significantly with bimodal outcomes, but some of the audiometric variables did. For CI>HA participants with a flatter audiometric configuration and better mid-frequency hearing, bimodal AzBio scores were significantly higher than the CI-alone score with the WB setting (BMWB) but not with other bandwidths. In contrast, CI>HA participants with more steeply sloping hearing loss and poorer mid-frequency thresholds (≥82.5 dB) had significantly higher bimodal AzBio scores in all bimodal conditions, and the BMWB did not differ significantly from the restricted bandwidth conditions. HA>CI participants with mild low-frequency hearing loss showed the highest levels of bimodal improvement over the best unimodal condition on CNC words. They were also less affected by HA bandwidth reduction compared with HA>CI participants with poorer low-frequency thresholds. CONCLUSIONS: The pattern of bimodal performance as a function of the HA bandwidth was found to be consistent with the degree and configuration of hearing loss for both patients with CI>HA performance and for those with HA>CI performance. Our results support fitting the HA for all bimodal patients with the widest bandwidth consistent with effective audibility.

Characteristics of Urban Inpatient Smokers With and Without Chronic Pain: Foundations for Targeted Cessation Programs.

BACKGROUND: Cigarette smoking and chronic pain are prevalent, comorbid conditions with significant consequences for individuals and society. Despite overlap between smoking and chronic pain, and pain's role as a potential barrier to quitting, there are no validated interventions targeted for smokers with chronic pains (SWCPs). OBJECTIVE: To compare characteristics of urban inpatient smokers with and without chronic pain to inform the development of SWCP-targeted cessation interventions. METHODS: This study reports partial results from a randomized comparative effectiveness trial of two smoking cessation interventions (NCT01363245). Participants were enrolled at two safety net hospitals in New York, NY in 2011-2014. Data were collected from the electronic health record and an interviewer-administered survey. Participants were considered to have chronic pain if they affirmed having "long-lasting, persistent, or chronic pain in the last six months" on survey. RESULTS: Among smokers assessed for pain (n = 1093), the prevalence of chronic pain was 44%. SWCPs were more likely to report depressive symptoms and to have a history of psychiatric diagnosis (nonsubstance related) than smokers without pain. Severe problems with mobility and with performing usual activities were more common in SWCPs. No significant difference was observed in sex, race, education, nicotine dependence level, confidence in quit ability, or history of substance misuse. Conclusions/Importance: Chronic pain in smokers admitted to safety net hospitals is prevalent and associated with hindered mobility, history of psychiatric diagnosis, and prescription opioid use. Urban safety net hospitals are an appropriate setting in which to pilot SWCP-targeted cessation programs, which should be designed with consideration for patients' psychiatric history and mobility status.

Transition of a Text-Based Insulin Titration Program From a Randomized Controlled Trial Into Real-World Settings: Implementation Study.

BACKGROUND: The Mobile Insulin Titration Intervention (MITI) program helps patients with type 2 diabetes find their correct basal insulin dose without in-person care. Requiring only basic cell phone technology (text messages and phone calls), MITI is highly accessible to patients receiving care in safety-net settings. MITI was shown in a randomized controlled trial (RCT) to be efficacious at a New York City (NYC) safety-net clinic where patients often have challenges coming for in-person care. In 2016, MITI was implemented as usual care at Bellevue Hospital (the site of the original RCT) and at Gouverneur Health (a second NYC safety-net clinic) under 2 different staffing models. OBJECTIVE: This implementation study examined MITI's transition into real-world settings. To understand MITI's flexibility, generalizability, and acceptability among patients and providers, we evaluated whether MITI continued to produce positive outcomes in expanded underserved populations, outside of an RCT setting. METHODS: Patients enrolled in MITI received weekday text messages asking for their fasting blood glucose (FBG) values and a weekly titration call. The goal was for patients to reach their optimal insulin dose (OID), defined either as the dose of once-daily basal insulin required to achieve either an FBG of 80-130 mg/dL (4.4-7.2 mmol/L) or as the reaching of the maximum dose of 50 units. After 12 weeks, if OID was not reached, the patients were asked to return to the clinic for in-person care and titration. MITI program outcomes, clinical outcomes, process outcomes, and patient satisfaction were assessed. RESULTS: MITI was successful at both sites, each with a different staffing model. Providers referred 170 patients to the program-129 of whom (75.9%, 129/170) were eligible. Of these, 113 (87.6%, 113/129) enrolled. Moreover, 84.1% (95/113) of patients reached their OID, and they did so in an average of 24 days. Clinical outcomes show that mean FBG levels fell from 209 mg/dL (11.6 mmol/L) to 141 mg/dL (7.8 mmol/L), P<.001. HbA1c levels fell from 11.4% (101 mmol/mol) to 10.0% (86 mmol/mol), P<.001. Process outcomes show that 90.1% of MITI's text message prompts received a response, nurses connected with patients 81.9% of weeks to provide titration instructions, and 85% of attending physicians made at least one referral to the MITI program. Satisfaction surveys showed that most patients felt comfortable sharing information over text and felt the texts reminded them to take their insulin, check their sugar, and make healthy food choices. CONCLUSIONS: This implementation study showed MITI to have continued success after transitioning from an RCT program into real-world settings. MITI showed itself to be flexible and generalizable as it easily fits into a second site staffed by general medical clinic-registered nurses and remained acceptable to patients and staff who had high levels of engagement with the program.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients.

IMPORTANCE: Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE: To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES: Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS: Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio [OR], 1.12 [95% CI, 1.03-1.21]) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33]), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16]). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22]; resident-only group, 13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18]; intern + resident group, 15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31]; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19]; resident-only group, 20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16]; intern + resident group, 22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23]). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE: Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.

Panel Management to Improve Smoking and Hypertension Outcomes by VA Primary Care Teams: A Cluster-Randomized Controlled Trial.

BACKGROUND: Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice. OBJECTIVE: We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education. DESIGN: We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans. PATRICIPANTS: Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans. INTERVENTIONS: Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone. MAIN MEASURES: Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services. KEY RESULTS: Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95% CI 1.2-1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95% CI 1.1-1.6) and Telehealth (OR = 1.7, 95% CI 1.4-2.1) than patients on control teams. CONCLUSIONS: Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

Who is being reached for a telephone-delivered intervention for patients with uncontrolled hypertension?

BACKGROUND: Telephone-delivered interventions to provide health counseling for complex chronic medical conditions are convenient, acceptable, and cost-effective. However, little is known about which patients are reached, their characteristics, and who benefits most from telephone-delivered counseling. MATERIALS AND METHODS: This study examined whether baseline characteristics are predictive of being easily reached for a monthly, telephone-delivered behavioral intervention to improve treatment adherence in Veterans with uncontrolled hypertension. Participants were to complete a telephone session once a month for 6 months. RESULTS: Participants completed an average of 5.71 out of a possible 6 sessions. Participants who were unmarried, African American, unemployed, or younger or did not complete high school required significantly more call attempts per completed session. CONCLUSIONS: Overall, telephone-delivered counseling is a feasible approach to reaching hypertensive patients. Patients who are married, Hispanic, retired, or older or graduated college may be easier to reach and engage in telephone-delivered counseling. Reaching patients with other sociodemographic characteristics may require more resources or alternate methods.

Optimizing the use of ketamine to reduce chronic postsurgical pain in women undergoing mastectomy for oncologic indication: study protocol for the KALPAS multicenter randomized controlled trial.

BACKGROUND: Mastectomies are commonly performed and strongly associated with chronic postsurgical pain (CPSP), more specifically termed postmastectomy pain syndrome (PMPS), with 25-60% of patients reporting pain 3 months after surgery. PMPS interferes with function, recovery, and compliance with adjuvant therapy. Importantly, it is associated with chronic opioid use, as a recent study showed that 1 in 10 patients continue to use opioids at least 3 months after curative surgery. The majority of PMPS patients are women, and, over the past 10 years, women have outpaced men in the rate of growth in opioid dependence. Standard perioperative multimodal analgesia is only modestly effective in prevention of CPSP. Thus, interventions to reduce CPSP and PMPS are urgently needed. Ketamine is well known to improve pain and reduce opioid use in the acute postoperative period. Additionally, ketamine has been shown to control mood in studies of anxiety and depression. By targeting acute pain and improving mood in the perioperative period, ketamine may be able to prevent the development of CPSP. METHODS: Ketamine analgesia for long-lasting pain relief after surgery (KALPAS) is a phase 3, multicenter, randomized, placebo-controlled, double-blind trial to study the effectiveness of ketamine in reducing PMPS. The study compares continuous perioperative ketamine infusion vs single-dose ketamine in the postanesthesia care unit vs placebo for reducing PMPS. Participants are followed for 1 year after surgery. The primary outcome is pain at the surgical site at 3 months after the index surgery as assessed with the Brief Pain Inventory-short form pain severity subscale. DISCUSSION: This project is part of the NIH Helping to End Addiction Long-term (HEAL) Initiative, a nationwide effort to address the opioid public health crisis. This study can substantially impact perioperative pain management and can contribute significantly to combatting the opioid epidemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT05037123. Registered on September 8, 2021.