Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis.

OBJECTIVE: To investigate whether medical nutrition therapy (MNT) provided by a registered dietitian experienced in chronic kidney disease (CKD) slows the progression of disease and improves nutrition-related biomarkers. DESIGN: Retrospective cohort study. SUBJECTS: The cohort included 265 participants from a regional nephrology center in a rural state; 147 of who received MNT were compared to a group that did not receive MNT and had started dialysis over a 10-year period. INTERVENTION: MNT by a registered dietitian with expertise in CKD. MAIN OUTCOME MEASURE: Average time to dialysis, based on stage of CKD at baseline, was compared between groups. In addition, the effect of MNT on the change in biochemical measures for estimated glomerular filtration rate, blood urea nitrogen, albumin, CKD Mineral and Bone Disorder (MBD) markers (phosphorous, calcium, and intact parathyroid hormone) at baseline and at follow-up (dialysis initiation or most recent laboratories if dialysis was not started) was assessed. RESULTS: MNT group had less of a decline in estimated glomerular filtration rate than the non-MNT group (0.3 vs. 9.9 mL/minute/1.73 m(2), respectively) a mean difference of 9.6 (P < 0.001). When adjusted for stage using linear regression, the mean difference was greater (11.4, P < .001). Using survival analysis and Cox proportional hazards regression, the non-MNT group was 3.15 more likely to initiate dialysis. Stratified by Stages 3 and 4 that hazard ratio increased (3.47 and 3.45, respectively). Albumin and markers of CKD-MBD were more likely to be within normal limits in the MNT group. The results indicate that better outcomes occur when MNT is given at CKD Stage 3 or 4 rather than CKD Stage 5. CONCLUSIONS: Results suggest that people with CKD who received MNT were less likely to start dialysis and had improved nutritional biomarkers than participants who did not receive MNT.

Efficacy of a short course of complex lymphedema therapy or graduated compression stocking therapy in the treatment of post-thrombotic syndrome.

Treatment options for established post-thrombotic syndrome (PTS) are limited. Complex lymphedema therapy (CLT), a non-invasive treatment that improves lymphatic flow, may have the potential to improve PTS. We conducted a single-center, investigator-blind, randomized controlled trial of 31 patients with a clinically established diagnosis of PTS and compared the efficacy of graduated compression stockings alone (30-40 mmHg) with CLT, a treatment that includes compression stockings, exercise, patient education, skin care and lymphatic drainage. Primary outcomes were the 1- and 3-month changes in PTS severity by the Villalta score and disease-specific quality of life using the VEINES-QOL (Venous Insufficiency Epidemiological and Economic Study Quality of Life) questionnaire. Analysis was by intent-to-treat. We found from a baseline average score of 9.9 points, CLT reduced mean PTS severity scores by -2.4 points (p=0.02) at the 1-month and -2.3 points (p=0.05) at the 3-month follow-up. Score reductions with stockings only were similar at -2.1 (p=0.03) and -3.3 points (p=0.03) at 1 and 3 months. The differences in score between treatments were not significant. Neither treatment significantly changed the VEINES-QOL score except in patients with severe disease. Patients with moderate to severe PTS derived the greatest benefit from either therapy and the two therapies differentially impacted PTS signs and symptoms. We found a short course of lymphedema therapy and compression stockings offer similar benefit in patients with PTS; however, larger studies are needed to further explore the potential use of CLT in PTS, particularly in patients with more severe disease. ClinicalTrials.gov Identifier: NCT00633971.

Comparison of telecommunication, community, and home-based Tai Chi exercise programs on compliance and effectiveness in elders at risk for falls.

OBJECTIVE: To compare the adherence to and effectiveness of Tai Chi exercise program through a live, interactive, telecommunication-based exercise (Tele-ex) with that of a similar program through a community center-based exercise (Comm-ex) and a home video-based exercise (Home-ex) among community-dwelling elders who are at risk for falls. DESIGN: Three groups randomized controlled trial with pretests and posttests. SETTING: Exercise programs were community-based, and the outcome measures were laboratory-based. PARTICIPANTS: Adults (N=64) age 65+ years with positive fall history in the previous year and/or significant fear of falling. INTERVENTION: A 24-form, Yang-style Tai Chi for 15 weeks, 3 hours a week. MAIN OUTCOME MEASURES: Exercise compliance, number of falls, fear of falling (Activities-specific Balance Confidence [ABC] score), self-perceived health (Medical Outcomes Study 36-Item Short Form Health Survey [SF-36]), Timed Up & Go (TUG), single leg stance (SLS), and body sway during quiet stance (medial-lateral foot center of pressure [ML-COP]). RESULTS: Tele-ex and Comm-ex groups demonstrated significantly higher exercise attendance and in-class practice time than the Home-ex group (P<.01) and significant reductions in the mean number of falls and injurious falls (P<.01). There were significant improvements posttraining in SLS, ABC, ML-COP, and Physical Health subscore of the SF-36 (P<.05). Both Tele-ex and Comm-ex groups demonstrated larger improvements than the Home-ex group in TUG, ML-COP, and the Social Function, Mental Health, and Physical Health subscores of the MOS SF-36. CONCLUSION: Compared with the Home-ex, the Tele-ex and Comm-ex groups are better in exercise compliance, fall reduction and balance and health improvements. Tele-ex is an effective, affordable, and acceptable choice of exercise for elders.

Attempts to stop or reduce marijuana use in non-treatment seekers.

Daily marijuana smokers (n=19) who intended to quit or reduce in the next month on their own called a phone each night for 28 nights to report marijuana use and reported intentions to change at the end of each week. Outcomes did not differ between those who initially planned to reduce vs. quit in the next month. Participants averaged three attempts to reduce and one attempt to quit during the 28 days. Participants reduced on 11% and abstained on 14% of days. Most participants were successful in reducing or abstaining on half or more of the days they attempted; however, only four participants (21%) reduced > or =50% for > or =7 consecutive days and only two (10%) abstained for that long. Abstinence or reduction did not appear to change alcohol or caffeine use. We conclude: (a) initial intentions are poor predictors of outcomes, (b) most users make multiple, short-lived attempts to change, (c) reduction was as common as abstinence, (d) many attempts to change are initially successful but few persist, and (e) other drug use does not appear to worsen with marijuana reduction or abstinence.

Human chorionic gonadotropin does not alter patterns of adrenal androgen secretion in primary human adrenal reticularis and fasciculata cell culture.

OBJECTIVE: Controversy surrounds the role of the ovary in maintaining postmenopausal androgen levels. Some postulate that aging ovaries are endocrinologically senescent and that menopausal levels of luteinizing hormone drive the adrenal cortex to secrete increasing amounts of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) as prohormones for subsequent peripheral bioconversion to maintain menopausal testosterone levels. We hypothesized that human chorionic gonadotropin (hCG), acting as an luteinizing hormone analog, would thus augment adrenal androgen secretion from primary human adrenocortical zona reticularis and zona fasciculata cell cultures. DESIGN: Human adrenal glands, obtained from a local organ donation program, were separated microscopically into reticularis and fasciculata zones and were cultured to confluence in serum-supplemented media, followed by a further incubation in defined media. They were then exposed to 24 hours of varying hCG doses, followed by an incubation with defined media and pregnenolone. Supernatants were assayed for adrenal androgens and cortisol. Data were expressed as the molar ratio of (DHEA+ DHEAS)/cortisol and the molar ratio of DHEA/DHEAS. For each of the four runs, mean molar ratios were compared by analysis of variance. RESULTS: For each of the four runs, the molar ratio was increased 17- to 157-fold in the reticularis compared with the fasciculata cells, indicating efficient zonal separation. Addition of hCG did not alter the molar ratios of adrenal androgens to cortisol or DHEA/DHEAS for either cell type. CONCLUSIONS: Addition of hCG to human adrenal reticularis or fasciculata cells does not seem to change the pattern of secretion of adrenal androgens or cortisol. It is thus unlikely that luteinizing hormone plays a significant role as an adrenal androgen secretagogue, at least with short-term exposure.