Fixed-Dose Phenobarbital Versus As-Needed Benzodiazepines for the Management of Alcohol Withdrawal in Acute Care General Internal Medicine.

OBJECTIVES: The management of patients at risk of severe alcohol withdrawal is challenging because conventional treatment with as-needed benzodiazepines may be ineffective. We created a fixed-dose phenobarbital protocol and compared patient outcomes using this protocol with an as-needed benzodiazepine protocol. METHODS: Patients admitted from the emergency department (ED) to General Medicine from January 1 to June 30, 2022 and treated for alcohol withdrawal with a novel phenobarbital protocol were compared with all of the patients admitted from the ED to General Medicine from January 1 to June 30, 2018, and treated with as-needed benzodiazepines. The primary outcome was a composite of intensive care unit (ICU) transfer or mortality. Secondary outcomes included mortality, ICU transfer, seizure, length of stay, excess sedation, delirium, against medical advice discharge, 30-day re-admission, 30-day ED reevaluation, and antipsychotic use. RESULTS: There were 54 patients in the phenobarbital group and 197 in the benzodiazepine group. The phenobarbital group was less medically complex but had more risk factors for severe withdrawal. There was no difference in the primary outcome, although there was a trend toward benefit in the phenobarbital group (3.7 vs 8.1%, P = 0.26), and there was a lower incidence of delirium in the phenobarbital cohort (0 vs 8.6%, P = 0.03). Secondary outcome trends favored phenobarbital, with lower mortality, ICU transfer, seizure, oversedation, against medical advice discharge, and 30-day re-admissions. A subgroup analysis accounting for differences in patient populations in the primary analysis found similar results. CONCLUSIONS: Phenobarbital is as safe and effective as benzodiazepine-based protocols for the treatment of high-risk alcohol withdrawal, with lower rates of delirium.

Student High Value Care Initiative: a Longitudinal Model for Student-Led Implementation and Scholarship.

BACKGROUND: Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education. AIM: To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives. SETTING: A tertiary medical center affiliated with a medical school in New York City. PARTICIPANTS: First year medical students, junior faculty in hospital medicine, and a senior faculty course director. PROGRAM DESCRIPTION: The Student High Value Care initiative is a longitudinal initiative comprised of six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4), Institutional support, (5) scholarship, and (6) student leadership. PROGRAM EVALUATION: During the first 3 years, 68 medical students and ten junior faculty participated in 10 quality improvement projects. Nine projects were successful in their measured outcomes, with statistically significant improvements. Nine had an abstract accepted to a regional or national meeting, and seven produced publications in peer-reviewed literature. DISCUSSION: In the first 3 years of the initiative, we successfully engaged medical students and junior faculty to create and support the implementation of successful quality improvement initiatives. Since that time, the program continues to offer meaningful mentorship and scholarship opportunities.

Post-TKA abelacimab reduced VTE at 8 to 12 d compared with enoxaparin.

SOURCE CITATION: Verhamme P, Yi BA, Segers A, et al. Abelacimab for prevention of venous thromboembolism. N Engl J Med. 2021;385:609-17. 34297496.

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.

BACKGROUND: It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS: We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. RESULTS: In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority). CONCLUSIONS: In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.).

Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper.

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.

Correlation of Body Composition and Low Back Pain Severity in a Cross-Section of US Veterans.

OBJECTIVE: Back pain is more prevalent in the obese, but whether back pain severity is directly correlated to obesity in veterans is unknown. We sought to determine if there was a correlation between body composition and low back pain severity in a sample of veterans. The hypothesis was that veterans with higher body mass index values would report higher low back pain severity scores. METHODS: This study was a retrospective chart review of 1768 veterans presenting to a Veterans Affairs chiropractic clinic with a chief complaint of low back pain between January 1, 2009 and December 31, 2014. Spearman's rho was used to test for correlation between body composition as measured by body mass index and low back pain severity as measured by the Back Bournemouth Questionnaire. RESULTS: On average, the sample was predominantly male (91%), older than 50, and overweight (36.5%) or obese (48.9%). There was no correlation between body mass index and Back Bournemouth Questionnaire scores, r = .088, p < .001. CONCLUSIONS: The majority of veterans with low back pain in this sample were either overweight or obese. There was no correlation between body composition and low back pain severity in this sample of veterans.

Chiropractic Management for US Female Veterans With Low Back Pain: A Retrospective Study of Clinical Outcomes.

OBJECTIVE: The purpose of this study was to determine if female US veterans had clinically significant improvement in low back pain after chiropractic management. METHODS: This is a retrospective chart review of 70 courses of care for female veterans with a chief complaint of low back pain who received chiropractic management through the VA Western New York Healthcare System in Buffalo, New York. A paired t test was used to compare baseline and discharge outcomes for the Back Bournemouth Questionnaire. The minimum clinically important difference was set as a 30% improvement in the outcome measure from baseline to discharge. RESULTS: The average patient was 44.8 years old, overweight (body mass index 29.1 kg/m2), and white (86%). The mean number of chiropractic treatments was 7.9. Statistical significance was found for the Back Bournemouth Questionnaire outcomes. The mean raw score improvement was 12.4 points (P < .001), representing a 27.3% change from baseline with 47% of courses of care meeting or exceeding the minimum clinically important difference. CONCLUSION: For our sample of female veterans with low back pain, clinical outcomes from baseline to discharge improved under chiropractic care. Although further research is warranted, chiropractic care may be of value in contributing to the pain management needs of this unique patient population.

Primary care utilization among veterans with chronic musculoskeletal pain: a retrospective chart review.

OBJECTIVE: Patients with chronic pain have been shown to be more frequent utilizers of primary care, a contributor to increased health care costs. This study aimed to clarify which patient factors predict primary care utilization among veterans with chronic pain. DESIGN: Data were gathered from the electronic medical records of veterans who used Veterans Affairs primary care services from 2003 to 2009 in upstate New York. Chronic pain cases (N = 792) were those veterans diagnosed with a musculoskeletal condition of the hip, knee, or lower back during two or more primary care encounters over a period ≥ 3 months. Cases were frequency matched by age to controls, or those veterans who did not have a chronic musculoskeletal condition of the hip, knee, or lower back. Demographic information, medical and psychiatric diagnoses, medication use, and other health-related factors were used in regression models to predict primary care utilization. RESULTS: Cases consistently accrued more primary care encounters than controls during each year of the observation period. Cases also accrued more encounters from specialty medicine clinics, chronic pain clinics, and behavioral health clinics co-located in primary care. The contribution of mental health factors to care utilization differed by case-control status. Diagnosis of depression and substance use disorders were predictors of care utilization only among controls, whereas anxiety disorders, use of anxiolytics, and adjustment disorders were predictors only among cases. Cases with a co-occurring anxiety disorder had a greater than twofold increased risk (odds ratio = 2.36, 95% confidence interval = 1.32-4.22) of being in the top 10% of the distribution of total primary care utilization. CONCLUSIONS: Mental health conditions that commonly co-occur with chronic musculoskeletal pain contribute to greater health care utilization. Improved screening and early intervention for these disorders in primary care may improve patient outcomes and stem high rates of care utilization of veterans.

Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach.

BACKGROUND: While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. OBJECTIVE: We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. DESIGNS, SETTINGS AND PARTICIPANTS: A quality improvement initiative was implemented across 11 safety net hospitals in New York City. INTERVENTION: The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. RESULTS: Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.

Chiropractic care and public health: answering difficult questions about safety, care through the lifespan, and community action.

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

Chiropractic Clinical Outcomes Among Older Adult Male Veterans With Chronic Lower Back Pain: A Retrospective Review of Quality-Assurance Data.

Objective: The purpose of this study was to determine whether a sample of older adult male U.S. veterans demonstrated clinically and statistically significant improvement in chronic lower back pain on validated outcome measures after a short course of chiropractic care. Methods: We performed a retrospective review of a quality-assurance data set of outcome metrics for male veterans, aged 65 to 89 years, who had chronic low back pain, defined as pain in the lower back region present for at least 3 months before evaluation. We included those who received chiropractic management from January 1, 2010, to December 31, 2018. Paired t tests were used to compare outcomes after 4 treatments on both a numeric rating scale (NRS) and the Back Bournemouth Questionnaire (BBQ). The minimum clinically important difference (MCID) was set at 30% change from baseline. Results: There were 217 individuals who met the inclusion criteria. The mean NRS score change from baseline was 2.2 points, representing a 34.1% reduction (t = 13.5, P < .001). The mean score change for BBQ was 14.7 points, representing a 35.9% reduction (t = 16.7, P < .001). The percentage of participants reaching the MCID for the NRS was 57% (n = 124) and for the BBQ was 59% (n = 126), with 41% (n = 90) of the sample reaching the MCID for both the NRS and BBQ. Conclusion: This retrospective review revealed clinically and statistically significant improvement in NRS and BBQ scores for this sample of older male U.S. veterans treated with chiropractic management for chronic low back pain.

Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline.

BACKGROUND: The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS: Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS: A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS: Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline.

BACKGROUND: The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS: Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS: A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS: Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Chiropractic management for veterans with neck pain: a retrospective study of clinical outcomes.

OBJECTIVE: The purpose of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients. METHODS: This is a retrospective case series of 54 veterans with a chief complaint of neck pain who received chiropractic care through a Veterans Health Administration medical center. Descriptive statistics and paired t tests were used with the numeric rating scale and Neck Bournemouth Questionnaire serving as the outcome measures. A minimum clinically important difference was set as 30% improvement from baseline for both outcomes. RESULTS: The mean number of chiropractic treatments was 8.7. For the numeric rating scale, the mean raw score improvement was 2.6 points, representing 43% change from baseline. For the Neck Bournemouth Questionnaire, the mean raw score improvement was 13.9 points, representing 33% change from baseline. For both measures, 36 (67%) patients met or exceeded the minimum clinically important difference. CONCLUSION: Mean chiropractic clinical outcomes were both statistically significant and clinically meaningful for this sample of veterans presenting with neck pain.

An Essential Guide to Chiropractic in the United States Military Health System and Veterans Health Administration.

OBJECTIVE: The purpose of this article is to provide an essential overview of chiropractic services in United States military and veterans' health care systems. METHODS: We reviewed literature, legislation, and policies from 1936 through September 2021 pertaining to chiropractic services in the United States military and veterans' health systems. Using these sources and our combined experience in these systems, we identified fundamental themes in the delivery of chiropractic care in the health care systems of the Department of Defense (providing health care for active duty service members) and the Department of Veterans Affairs (providing health care for veterans) in main topic areas. RESULTS: We identified 7 main topic areas relevant to the 2 systems: populations served by chiropractors; health care systems; integration; utilization and supply of chiropractic care; vetting of chiropractors; roles and evaluation of chiropractors; and oversight and leadership. Key information about chiropractic care in these systems was synthesized into the main topic areas. Benefits of high-quality within-system chiropractic care to active-duty service members and veterans are presented. The assets that within-system chiropractors bring to the Department of Defense and Department of Veterans Affairs health care systems are discussed for each main topic area. CONCLUSION: This article contains an essential overview of chiropractic services in the Department of Defense and the Department of Veterans Affairs. It offers clarity regarding the integration of chiropractic services into these health care systems and includes a 1-page brief of talking points that may help better inform ongoing discussions of chiropractic services in these 2 different but intertwined environments.

A Rapid Guidance Process for the Development of an Anticoagulation Protocol in the COVID-19 Pandemic.

Health care systems have encountered unprecedented challenges during the coronavirus disease-2019 (COVID-19) pandemic, such as standardizing care in the absence of high-quality data. As an emblematic example, preliminary data and early anecdotal experience suggested that a major driver of COVID-19 pathophysiology was hypercoagulability, suggesting the need for aggressive anticoagulation. In this article, we describe the rapid guidance process for the development of an anticoagulation protocol for COVID-19. Preliminary evidence was collected from multidisciplinary experts within our institution to inform the first protocol draft. After implementation, we rapidly acquired data to inform a revision, with subsequent modifications based on higher quality data. The description of this process can inform other health systems when faced with a similar crisis characterized by high patient volumes, poor clinical outcomes, lack of proven effective therapies, and rapid flow of information from multiple sources of variable credibility.

Physician perceptions of documentation methods in electronic health records.

This study sought to determine physician, specialty and practice factors influencing choice of method for electronic health record (EHR) documentation: direct typing (DT), electronic transcription (ET), human transcription (HT), and scribes. A survey assessing physician documentation practices was developed and distributed online. The primary outcome was the proportion of physicians using each method. Secondary outcomes were provider-rated accuracy, efficiency, and ease of navigation on a 1-5 Likert scale. Means were compared using linear mixed models with Bonferroni adjustment. The 818 respondents were mostly outpatient (46%) adult (79%) physicians, practiced for a mean 15.8 years, and used DT for EHR documentation (72%). Emergency physicians were more likely to use scribes (p < 0.0001). DT was rated less efficient than all other methods (p < 0.0001). ET was rated less accurate than DT (p < 0.001) and HT (p < 0.001). HT was rated less easy to navigate than DT (p = 0.002) and scribe (p < 0.001), and ET less than scribe (p = 0.002). Two hundred and forty-three respondents provided free-text comments that further described opinions. DT was the most commonly used EHR method but rated least efficient. Scribes were rated easy to navigate and efficient but infrequently used outside of emergency settings. Further innovation is needed to design systems responsive to all physician EHR needs.

A Sleep Hygiene Intervention to Improve Sleep Quality for Hospitalized Patients.

INTRODUCTION: Poor sleep is a pervasive problem for hospitalized patients and can contribute to adverse health outcomes. METHODS: We aimed to improve self-reported sleep for patients on a general medicine ward as measured by the Richards-Campbell Sleep Questionnaire (RCSQ) as well as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question addressing quietness at night. We utilized a non-pharmacologic sleep hygiene bundle composed of a short script with sleep hygiene prompts, such as whether patients would like the shades closed or the lights turned off, as well as a sleep package including an eye mask, earplugs, lavender scent pad, and non-caffeinated tea. Relaxing music was played at bedtime and signs promoting the importance of quietness at night were placed around the unit. Front-line champions were identified to aid with implementation. RESULTS: A total of 931 patients received the intervention. In a sample of surveyed patients, we observed an increase in the RCSQ global score from 6.0 (IQR 3.0-7.0) to 6.2 (IQR 4.0-7.8) from the pre- to post- intervention periods (p = 0.041), as well as increases in three of the five individual survey components. Additionally, HCAHPS "quietness at night" score increased on the unit from 34.1% pre-intervention to 42.5% post-intervention. CONCLUSION: A nonpharmacologic sleep hygiene protocol paired with provider education and use of champions was associated with modest improvements in patients' perceived sleep and unit HCAHPS scores.