Suvorexant alters dynamics of the sleep-electroencephalography-power spectrum and depressive-symptom trajectories during inpatient opioid withdrawal.

STUDY OBJECTIVES: Opioid withdrawal is an aversive experience that often exacerbates depressive symptoms and poor sleep. The aims of the present study were to examine the effects of suvorexant on oscillatory sleep-electroencephalography (EEG) band power during medically managed opioid withdrawal, and to examine their association with withdrawal severity and depressive symptoms. METHODS: Participants with opioid use disorder (N = 38: age-range:21-63, 87% male, 45% white) underwent an 11-day buprenorphine taper, in which they were randomly assigned to suvorexant (20 mg [n = 14] or 40 mg [n = 12]), or placebo [n = 12], while ambulatory sleep-EEG data was collected. Linear mixed-effect models were used to explore: (1) main and interactive effects of drug group, and time on sleep-EEG band power, and (2) associations between sleep-EEG band power change, depressive symptoms, and withdrawal severity. RESULTS: Oscillatory spectral power tended to be greater in the suvorexant groups. Over the course of the study, decreases in delta power were observed in all study groups (ß = -189.082, d = -0.522, p = <0.005), increases in beta power (20 mg: ß = 2.579, d = 0.413, p = 0.009 | 40 mg ß = 5.265, d = 0.847, p < 0.001) alpha power (20 mg: ß = 158.304, d = 0.397, p = 0.009 | 40 mg: ß = 250.212, d = 0.601, p = 0.001) and sigma power (20 mg: ß = 48.97, d = 0.410, p < 0.001 | 40 mg: ß = 71.54, d = 0.568, p < 0.001) were observed in the two suvorexant groups. During the four-night taper, decreases in delta power were associated with decreases in depressive symptoms (20 mg: ß = 190.90, d = 0.308, p = 0.99 | 40 mg: ß = 433.33, d = 0.889 p = <0.001), and withdrawal severity (20 mg: ß = 215.55, d = 0.034, p = 0.006 | 40 mg: ß = 192.64, d = -0.854, p = <0.001), in both suvorexant groups and increases in sigma power were associated with decreases in withdrawal severity (20 mg: ß = -357.84, d = -0.659, p = 0.004 | 40 mg: ß = -906.35, d = -1.053, p = <0.001). Post-taper decreases in delta (20 mg: ß = 740.58, d = 0.964 p = <0.001 | 40 mg: ß = 662.23, d = 0.882, p = <0.001) and sigma power (20 mg only: ß = 335.54, d = 0.560, p = 0.023) were associated with reduced depressive symptoms in the placebo group. CONCLUSIONS: Results highlight a complex and nuanced relationship between sleep-EEG power and symptoms of depression and withdrawal. Changes in delta power may represent a mechanism influencing depressive symptoms and withdrawal.

Preoperative neutrophil-to-lymphocyte ratio is prognostic for early recurrence after curative intrahepatic cholangiocarcinoma resection.

Backgrounds/Aims: Within two years of surgery, 70% of resected intrahepatic cholangiocarcinoma (iCCA) recur. Better biomarkers are needed to identify those at risk of "early recurrence" (ER). In this study, we defined ER and investigated whether preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic-inflammatory index were prognostic of both overall relapse and ER after curative hepatectomy for iCCA. Methods: A retrospective cohort of patients who underwent curative-intent hepatectomy for iCCA between 2005 and 2017 were created. The cut-off timepoint for the ER of iCCA was estimated using a piecewise linear regression model. Univariable analyses of recurrence were conducted for the overall, early, and late recurrence periods. For the early and late recurrence periods, multivariable Cox regression with time-varying regression coefficient analysis was used. Results: A total of 113 patients were included in this study. ER was defined as recurrence within 12 months of a curative resection. Among the included patients, 38.1% experienced ER. In the univariable model, a higher preoperative NLR (> 4.3) was significantly associated with an increased risk of recurrence overall and in the first 12 months after curative surgery. In the multivariable model, a higher NLR was associated with a higher recurrence rate overall and in the ER period (≤ 12 months), but not in the late recurrence period. Conclusions: Preoperative NLR was prognostic of both overall recurrence and ER after curative iCCA resection. NLR is easily obtained before and after surgery and should be integrated into ER prediction tools to guide preoperative treatments and intensify postoperative follow-up.

The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending.

BACKGROUND: Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy. METHODS: Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars. RESULTS: Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases. CONCLUSION: Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

CONTEXTE: En raison de l'augmentation des coûts des soins de santé on attend des professionnels qu'ils mettent davantage l'accent sur les restrictions budgétaires et l'imputabilité. Nous avons voulu vérifier à quel point les chirurgiens sont conscients du coût des fournitures utilisés dans les cas de gastrectomie distale ouverte et laparoscopique. MÉTHODES: Des questionnaires ont été envoyés en 2015 aux chirurgiens de 8 hôpitaux universitaires de Toronto qui pratiquent la gastrectomie distale pour l'adénocarcinome de l'estomac. On demandait aux participants d'estimé le coût total, le type et le nombre de fournitures jetables requises pour une gastrectomie distale ouverte et laparoscopique. Nous avons déterminé l'exactitude des estimations en comparant les factures pour les interventions de gastrectomie distale effectuées entre le 1er janvier 2011 et le 31 décembre 2015. Toutes les valeurs sont présentées en dollars canadiens. RÉSULTATS: Parmi les 53 questionnaires envoyés, 12 sont revenus complétés (taux de réponse 23 %). Les estimations des chirurgiens pour le coût total des fournitures allaient de 500 $ à 3000 $ et de 1500 $ à 5000 $ pour les interventions ouvertes et laparoscopiques, respectivement. Le coût estimé des fournitures pour l'équipement nécessaire variait de 464 $ à 2055 $ pour les interventions ouvertes et de 1870 $ à 2960 $ pour les interventions laparoscopiques. Les factures soumises pour les équipements réellement utilisés ont été en moyenne de 821 $ (écart-type 543 $) (éventail 89 $-2613 $) pour les interventions ouvertes et de 2678 $ (écart-type 958 $) (éventail 835 $-4102 $) pour les interventions laparoscopiques. Les estimations des coûts totaux se situaient à plus ou moins 25 % du montant total médian des factures dans 1 réponse (9 %) pour les interventions ouvertes et dans 3 réponses (27 %) pour les interventions laparoscopiques. CONCLUSION: Les participants n'ont pas été en mesure d'estimer avec exactitude le coût des fournitures. Cet écart entre les coûts totaux réels et estimés représente une occasion de réduire les coûts peropératoires, de sélectionner les équipements de façon efficiente et de conclure des contrats d'achat en fonction de la valeur.

Triage of Rheumatology Referrals Facilitates Wait Time Benchmarks.

OBJECTIVE: In 2014 the Canadian Rheumatology Association published wait time benchmarks for inflammatory arthritis (IA) and connective tissue disease (CTD) to improve patient outcomes. This study's aim was to determine whether centralized triage and the introduction of quality improvement initiatives would facilitate achievement of wait time benchmarks. METHODS: Referrals from September to November 2012 were retrospectively triaged by an advanced practice physiotherapist (APP) and compared to referrals triaged by an APP from January to March 2014. Each referral was assigned a priority ranking and categorized into one of 2 groups: suspected IA/CTD, or suspected non-IA/CTD. Time to initial consult and time to notification from receipt of referral were assessed. RESULTS: A total of 558 (n = 227 and n = 331 from 2012 and 2014, respectively) referrals were evaluated with 35 exclusions. In 2012, there were 96 (42.5%) suspected IA/CTD and 124 (54.9%) suspected non-IA/CTD patients at the time of the initial consult. Mean wait times in 2012 for patients suspected to have IA was 33.8 days, 95% CI 27.8-39.8, compared to 37.3 days, 95% CI 32.9-41.7 in suspected non-IA patients. In 2014, there were 131 patients (43%) with suspected IA based on information in the referral letter. Mean wait times in 2014 for patients suspected to have IA was 15.5 days, 95% CI 13.85-17.15, compared to 52.2 days, 95% CI 46.3-58.1 for suspected non-IA patients. Time to notification of appointment improved from 17 days to 4.37 days. CONCLUSION: Centralized triage of rheumatology referrals and quality improvement initiatives are effective in improving wait times for priority patients as determined by paper referral.

Beyond the dollar: Influence of sociodemographic marginalization on surgical resection, adjuvant therapy, and survival in patients with pancreatic cancer.

BACKGROUND: The single-payer universal health care system in Ontario, Canada creates a setting with reduced socioeconomic barriers to treatment. Herein, the authors sought to elucidate the influence of sociodemographic marginalization on receipt of pancreatectomy, overall survival (OS), and receipt of adjuvant treatment among patients diagnosed with pancreatic cancer at the population level using an observational cohort study design. METHODS: Patients diagnosed with pancreatic cancer in Ontario between January 2005 and January 2010 were identified using the provincial cancer registry and linked to administrative databases. Census data obtained from each patient's postal code were used as a proxy for that patient's median income, residential instability, material deprivation, ethnic concentration, and dependency (percentage aged <15 years, aged >65 years, and unemployed). Surgical specimen pathology reports were abstracted for histopathology and margin status. Independent predictors of undergoing pancreatectomy, OS after surgical resection, and receipt of adjuvant treatment were identified by logistic regression and Cox proportional hazards analysis. RESULTS: Of the 6296 patients diagnosed with pancreatic cancer, 820 (13%) underwent resection of their tumor. Increasing levels of residential instability (odds ratio [OR], 0.86; 95% confidence interval [95% CI], 0.80-0.94) and material deprivation (OR, 0.86; 95% CI, 0.79-0.94) predicted a decreased likelihood of undergoing surgical resection. Patients living in rural areas (OR, 0.68; 95% CI, 0.51-0.91) and those living in urban areas with lower incomes (OR range, 0.49-0.77) were found to have a lower likelihood of undergoing surgical resection compared with patients in the urban areas with the highest income. After surgical resection, an association between sociodemographic marginalization with OS or receipt of adjuvant treatment was not identified. CONCLUSIONS: Sociodemographic marginalization exerts its influence early in the pancreatic cancer care continuum, and appears to be associated more with which patients undergo surgical resection than the receipt of adjuvant treatment. Cancer 2016;122:3175-82. © 2016 American Cancer Society.

Estimated cost of universal public coverage of prescription drugs in Canada.

BACKGROUND: With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada. METHODS: We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator. RESULTS: Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes. INTERPRETATION: The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government.

Xenaderm: an essential wound care therapy.

OBJECTIVE: To discuss the clinical efficacy, indications, and application of Xenaderm in wound care management. DATA SOURCES: Healthcare literature from Medline and Ovid databases that focus on clinical trials and case studies that used Xenaderm to evaluate duration of wound healing. STUDY SELECTION: Inclusion criteria for article selection: (1) articles on clinical trials and case studies in which Xenaderm was the focus of the wound therapy, (2) articles written in English, and (3) articles published later than 2003. Studies that did not meet the inclusion criteria were excluded. CONCLUSION: Outcomes from clinical trials demonstrate that Xenaderm is efficacious and successful in healing wounds twice as fast as saline-treated wounds. Use of Xenaderm is considered safe and cost-effective. Xenaderm is eligible to be included in the wound care management algorithm and is recommended to be used on most partial-thickness wounds. Results from clinical trials show that Xenaderm is an essential topical therapy to facilitate wound healing, decrease hospital financial costs, and improve the quality of life for patients who acquire iatrogenic skin damage.