Medical diagnoses of heat wave-related hospital admissions in older adults.

Heat waves have been associated with adverse human health effects, including higher rates of all-cause and cardiovascular mortality, and these health effects may be exacerbated under continued climate change. However, specific causes of hospitalizations associated with heat waves have not been characterized on a national scale. We systematically estimated the risks of cause-specific hospitalizations during heat waves in a national cohort of 23.7 million Medicare enrollees residing in 1943 U.S. counties during 1999-2010. Heat waves were defined as ≥2 consecutive days exceeding the county's 99th percentile of daily temperatures, and were matched to non-heat wave periods by county and week. We considered 50 outcomes from broad disease groups previously associated with heat wave-related hospitalizations, and estimated cause-specific relative risks (RRs) of hospital admissions on heat wave days. We identified 11 diagnoses with a higher admission risk on heat wave days, with heat stroke and sunstroke having the highest risk (RR = 22.5, [95% CI 14.9-34.2]). Other diseases with elevated risks included fluid and electrolyte disorders [(Hyperosmolality RR = 1.4, [95% CI 1.1-1.3]; Hypoosmolaltiy RR = 1.2, [95% CI 1.1-1.3])] and acute kidney failure (RR = 1.1, [95% CI 1.1-1.2]). These risks tended to be higher under more severe heat wave events. In addition, risks were higher among adults in the oldest (≥85) category (reference: 65-74) for volume depletion and heat exhaustion. Several causes of hospitalization identified are preventable, and public health interventions, including early warning systems and plans targeting risk factors for these illnesses, could reduce adverse effects of heat in the present and under climate change.

Eustachian Tube Quality of Life and Severity of Disease in Patients With Chronic Rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) has long been a suspected risk factor for Eustachian tube dysfunction (ETD). However, there have been few studies quantifying the presence of ETD in CRS patients. We sought to determine the prevalence of ETD symptoms in patients undergoing functional endoscopic sinus surgery (FESS) for CRS using the validated 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate the ETDQ-7 scores with scores of CRS symptom severity based on the 22-item Sino-Nasal Outcome Test (SNOT-22). METHODS: Patients for FESS were preoperatively administered both the ETDQ-7 and the SNOT-22 validated quality of life instruments. Pearson and Spearman correlation coefficients were calculated. Changes in ETDQ-7 were measured at 3 months and differences were compared via paired t test. RESULTS: A total of 82 patients completed the surveys. Thirty-nine (47.6%) patients had ETDQ-7 score ≥14.5, signifying clinically significant ETD symptoms. The mean ETDQ-7 score of the study population was 15.8 ± 8.8, and the mean SNOT-22 score was 37.5 ± 19.7. The Pearson and Spearman correlation coefficients between ETDQ-7 and the total SNOT-22 score were 0.52 (P > .0001) and 0.51 (P < .0001), respectively. There was significant improvement in ETDQ-7 scores postoperatively. CONCLUSION: While the association between ETD and CRS has long been known, this is one of the few prospective patient studies evaluating otologic symptoms in a CRS population. We found that a significant percentage of CRS patients suffer from ETD symptoms based on patient-reported subjective outcome measures. This study demonstrates that otologic symptoms increase with CRS severity and improve after FESS.

Voice-Related Quality of Life in Patients with Chronic Rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) has long been associated with vocal dysfunction. However, studies quantifying the presence of voice dysfunction in CRS patients or the effects of functional endoscopic sinus surgery (FESS) are sparse. The goal of this study was to determine the voice-related quality of life in patients undergoing FESS for CRS using the validated Voice Related Quality of Life Survey (VRQL). We correlated the preoperative VRQL scores to the Sino-Nasal Outcome Test (SNOT-22) scores, and we determined the effect of FESS on postoperative VRQL scores. METHODS: Consecutive patients undergoing FESS were preoperatively administered both the VRQL and the SNOT-22 surveys. Spearman (ρ) and Pearson (r) correlation coefficients were calculated. The VRQL was mailed to patients postoperatively between 3 and 6 months. The paired t-test was used to compare pre- and post-FESS scores. RESULTS: A total of 102 patients were enrolled, and 81 patients completed the two surveys. A total of 51 (62.9%) patients had raw VRQL score ≥ 10, signifying presence of significant vocal symptoms. The mean ± standard deviation (SD) raw VRQL score of the entire study population was 12.4 ± 4.6, and the mean SNOT-22 score was 37.8 ± 19.2. The Spearman correlation coefficient between VRQL and the total SNOT-22 score was 0.34 (P =.002), and the Pearson correlation coefficient was 0.36 (P = .001). Both correlations were similar, demonstrating that increasing severity of CRS symptoms correlates with decreasing voice-related quality of life (QOL). Seventy patients completed the postoperative survey for an 86% retention rate. Thirty-six of these patients had abnormal preoperative VRQL scores, and these patients improved significantly after FESS. The mean preoperative versus postoperative raw scores were 15.2 ± 5.6 versus 12.5 ± 4.1, respectively (P = .003). CONCLUSION: This study demonstrates the increasing presence of vocal complaints with increasing severity of CRS. It also demonstrates that VRQL scores improve after FESS in those patients with preoperative vocal complaints. LEVEL OF EVIDENCE: IV.

A Shared Decision-Making Intervention to Guide Opioid Prescribing After Cesarean Delivery.

OBJECTIVE: To assess whether a shared decision-making intervention decreases the quantity of oxycodone tablets prescribed after cesarean delivery. TECHNIQUE: A tablet computer-based decision aid formed the basis of a shared decision-making session to guide opioid prescribing after cesarean delivery. Women first received information on typical trajectories of pain resolution and expected opioid use after cesarean delivery and then chose the number of tablets of 5 mg oxycodone they would be prescribed up to the institutional standard prescription of 40 tablets. EXPERIENCE: From April 11, 2016, to June 10, 2016, 105 women were screened, 75 were eligible, and 51 consented to participate; one patient was excluded after enrollment as a result of prolonged hospitalization. The median number of tablets (5 mg oxycodone) women chose for their prescription was 20.0 (interquartile range 15.0-25.0), which was less than the standard 40-tablet prescription (P<.001). CONCLUSION: A shared decision-making approach to opioid prescribing after cesarean delivery was associated with approximately a 50% decrease in the number of opioids prescribed postoperatively in this cohort compared with our institutional standard prescription. This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute postcesarean pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02770612.

Patterns of Opioid Prescription and Use After Cesarean Delivery.

OBJECTIVE: To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery. METHODS: We conducted a survey at six academic medical centers in the United States from September 2014 to March 2016. Women who had undergone a cesarean delivery were contacted by phone 2 weeks after discharge and participated in a structured interview about the opioid prescription they received on discharge and their oral opioid intake while at home. RESULTS: A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30-40), the median number consumed was 20 (interquartile range 8-30), and leftover was 15 (interquartile range 3-26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. CONCLUSION: The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

Reproductive health and the environment: Counseling patients about risks.

Endocrine-disrupting chemicals (EDCs) are associated with reproductive complications such as infertility, pregnancy complications, poor birth outcomes, and child developmental abnormalities, although not all chemicals of concern are EDCs. Pregnant patients and women of childbearing age need reasonable advice about environmental contaminants and reproductive health.