Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments.

Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.

We aimed to investigate social determinants of health, such as race and type of insurance, and their role in patients' attendance of pain clinic appointments. Data were collected over several years and statistical analysis was performed on over 145,000 patient encounters. It was found that patients with Medicaid and Medicare were less likely to attend appointments compared with patients with commercial insurance. Black or African­American patients were also less likely to attend compared with White patients. Spanish speaking patients were more likely to attend compared with English speaking patients, showing that previous interventions aimed at reducing the language barrier for Spanish speaking patients continue to be successful after many years. Overall, significant disparities exist in pain clinic attendance based upon social determinants of health. Further research is needed to investigate reasons and potential areas of interventions. Patients insured with Medicare and Medicaid may also have greater transportation issues, a potential focus for further studies and targeted interventions.

Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018.

BACKGROUND AND AIM: Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients. METHODS: We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed. RESULTS: A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001). CONCLUSION: Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.

Economic burden of maternal mortality in the USA, 2018-2020.

Aim: To evaluate the economic burden of age- and race/ethnicity-based US maternal mortality disparities. Economic burden is estimated by years of potential life lost (YPLL) and value of statistical life (VSL). Methods: Maternal mortality counts (2018-2020) were obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database. Life-expectancy data were obtained from the Social Security actuarial tables. YPLL and VSL were calculated and stratified by age (classified as under 25, 25-39, and 40 and over) and race/ethnicity (classified as Hispanic, non-Hispanic White, non-Hispanic Black). Results: Economic measures associated with maternal mortality increased by an estimated 30%, from a YPLL of 32,824 and VSL of US$7.9 billion in 2018 to a YPLL of 43,131 and VSL of US$10.4 billion in 2020. Conclusion: Our findings suggest that age, race and ethnicity are major drivers of the US maternal mortality economic burden.

COVID-19 complications in males and females: recent developments.

Aim: To provide a comprehensive understanding of the varying effects of SARS-CoV-2 infection based on sex. Methods: A PubMed search of 470 primary articles was performed, with inclusion based on relevance (sex differences discussed in the target COVID population) and redundancy. PubMed was queried based on title for the keywords "SEX" and "COVID" or "SARS" between 2020 and 2022. Results: For COVID-19, males have increased risk for infectivity and intensive care unit admission and worse overall outcomes compared with females. Genetic predispositions, sex hormones, immune system responses and non-biological causes all contribute to the disparity in COVID-19 responses between the sexes. COVID-19 sex-related determinants of morbidity and mortality remain unclear. Conclusions: Male sex is a risk factor for several overall worse outcomes related to COVID-19. Investigating the sex impact of COVID-19 is an important part of understanding the behavior of the disease. Future work is needed to further explore these relationships and optimize the management of COVID-19 patients based on sex.

The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis.

BACKGROUND: Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy. METHODS: The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant. RESULTS: The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort). CONCLUSION: Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.

Strategic testing plan for ambulatory surgery centers after the COVID-19 pandemic.

As the curve continues to flatten during the severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic, and more physicians resume outpatient clinical work, the question arises of how to ensure the safety of the patients and staff while performing cases. Many institutions and health-care offices have turned to screening questionnaires to determine the likelihood of coronavirus disease 2019 (COVID-19) positivity. However, screening questionnaires are woefully inadequate as studies have shown that roughly 6.4% to 50% of patients may spread this virus without any symptoms. In this study, we have outlined a proposal to restart elective procedures after the curve has flattened in a certain locale, particularly for ambulatory surgery centers (ASCs). Until additional data are collected for specific sensitivity and specificity values for PCR testing, we recommend performing 2 consecutive polymerase chain reaction (PCR) tests to minimize false negative rates. The algorithm described in this study can help ASCs begin their practices and provide local public health officials with valuable data that can help establish true sensitivity and specificity rates for these tests.

Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions.

Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.

Lay abstract Total knee arthroplasty (TKA), also known as 'knee replacement', is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Historically, pain management after TKA has involved opioids, but in light of recent extensive opioid dependence and consumption, pain management plans that incorporate other non-opioid techniques should be considered. This study identifies the best practices for postoperative TKA pain management through a literature review of the last 3 years. Studies utilizing interventional techniques such as local analgesia and nerve blocks, as well as pharmacologic options (involving the administration of medicines), were reviewed on the following databases: PubMed, Embase, Ovid Medline and Scopus. The main outcomes analyzed were the effect of these different approaches on pain reduction, opioid use reduction and improvements in functional mobility or strength of the quadriceps muscle in the thigh following TKA surgery. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.

Interventional Spine and Pain Procedure Credentialing: Guidelines from the American Society of Pain & Neuroscience.

BACKGROUND: The discipline of interventional pain management has changed significantly over the past decade with an expected greater evolution in the next decade. Not only have the number of procedures increased, some of the procedures that were created for spine surgeons are becoming more facile in the hands of the interventional pain physician. Such change has outpaced academic institutions, societies, and boards. When a pain physician is in the credentialing process for novel procedure privileges, it can leave the healthcare system in a challenging situation with little to base their decision upon. METHODS: This paper was developed by a consensus working group from the American Society of Pain and Neuroscience from various disciplines. The goal was to develop processes and resources to aid in the credentialing process. RESULTS: These guidelines from the American Society of Pain and Neuroscience provide background information to help facilities create a process to appropriately credential physicians on novel procedures. They are not intended to serve as a standard or legal precedent. CONCLUSION: This paper serves as a guide for facilities to credential physicians on novel procedures.

Recommendations and Guidance for Steroid Injection Therapy and COVID-19 Vaccine Administration from the American Society of Pain and Neuroscience (ASPN).

To date, COVID-19 has spread to more than 108 million people globally, with a death toll surpassing 2 1/2 million. With the United States Food and Drug Administration (FDA) approval of two highly effective COVID-19 vaccines from Pfizer-BioNtech and Moderna, we now have a novel approach to contain COVID-19 related morbidity and mortality. Chronic pain care has faced unprecedented challenges for patients and providers in this ever-changing climate. With the approval of COVID-19 vaccines, we now face questions relating to the potential effects of pain treatments utilizing steroids on vaccine efficacy. In this analysis, we address these issues and provide guidance for steroid therapies based on available data and expert recommendations.

Advances in the interventional management of neuropathic pain.

The management of neuropathic pain, defined as pain as a result of a lesion or disease in the somatosensory nervous system, continues to be researched and explored. As conventional methods demonstrate limited long-term efficacy, there is a significant need to discover therapies that offer both longitudinal and sustained management of this highly prevalent disease, which can be offered through interventional therapies. Tricyclic antidepressants (TCAs), gabapentinoids, lidocaine, serotonin norepinephrine reuptake inhibitors (SNRIs), and capsaicin have been shown to be the most efficacious pharmacologic agents for neuropathic pain relief. With respect to infusion therapies, the use of intravenous (IV) ketamine could be useful for complex regional pain syndrome, fibromyalgia, and traumatic spinal cord injury. Interventional approaches such as lumbar epidurals are a reasonable treatment choice for up to 3 months of pain relief for patients who failed to respond to conservative treatment, with a "B" strength of recommendation and moderate certainty. Neuroablative procedures like pulsed radiofrequency ablation work by delivering electrical field and heat bursts to targeted nerves or tissues without permanently damaging these structures, and have been recently explored for neuropathic pain relief. Alternatively, neuromodulation therapy is now recommended as the fourth line treatment of neuropathic pain after failed pharmacological therapy but prior to low dose opioids. Finally, the intrathecal delivery of various pharmacologic agents, such as quinoxaline-based kappa-opioid receptor agonists, can be utilized for neuropathic pain relief. In this review article, we aim to highlight advances and novel methods of interventional management of neuropathic pain.

Geriatric Patients Undergoing Outpatient Surgery in the United States: A Retrospective Cohort Analysis on the Rates of Hospital Admission and Complications.

INTRODUCTION:  This study is a retrospective cohort analysis that describes key clinical outcomes in elderly individuals who undergo outpatient surgical procedures. In particular, we report same-day admission, 30-day mortality, 30-day complications, and 30-day readmission rates for three separate age groups undergoing frequent outpatient, general surgical procedures. METHODS: Patients ≥18 years old who underwent the 10 most common outpatient surgical procedures in the National Surgical Quality Improvement Program database from 2017 to 2019 and who underwent general anesthesia were included in the study. The primary outcome of interest was hospital admission, defined as hospital length of stay >0 days. Secondary outcomes of interest included 30-day readmission, 30-day mortality, and 30-day postoperative complications. The primary exposure variable of interest was age, which was divided into <65 years of age (reference cohort), 65-79 years of age, and ≥80 years of age. For univariate analysis, to measure differences in the outcomes and patient characteristics, we used chi-squared tests. Our primary method of analysis was multivariable logistic regression. RESULTS: Those who were ≥80 and 65-79 years of age compared to <65 years of age had higher odds of same-day admission, 30-day mortality, composite postoperative complications, and readmission. Patients who were ≥80 years old had higher odds of same-day admission for laparoscopic cholecystectomy, partial mastectomy, laparoscopic inguinal hernia repair, inguinal hernia repair, umbilical hernia repair, laparoscopic removal of adnexal structures, and lumbar laminotomy. CONCLUSION: Increasing age, particularly greater than 80 years or older and 65-79 years of age group, is associated with an increased rate of same-day hospital admissions and complications after ambulatory surgery.

Efficacy of Serology Testing in Predicting Reinfection in Patients With SARS-CoV-2.

In many parts of the United States, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases have reached peak infection rates, prompting administrators to create protocols to resume elective cases. As elective procedures and surgeries get scheduled, ambulatory surgery centers (ASCs) must implement some form of widespread testing in order to ensure the safety of both the ASC staff and the patients being seen. The US Centers for Disease Control and Prevention (CDC) recently announced the approval of new serological testing for SARS-CoV-2, a test that can indicate the presence of IgM and IgG antibodies in the serum against viral particles. However, the possibility for reinfection raises questions about the utility of this new serological test, as the presence of IgG may not correspond to long-term immunity. SARS-CoV-2 has been known to form escape mutations, which may correspond to a reduction in immunoglobulin binding capacity. Patients who develop more robust immune responses with formation of memory CD8+ T-cells and helper CD4+ T-cells will be the most equipped if exposed to the virus, but, unfortunately, the serology test will not help us in distinguishing those individuals. Given the inherent disadvantages of serological testing, antibody testing alone should not be used when deciding patient care and should be combined with polymerase chain reaction testing.

Single arm prospective multicenter case series on the use of burst stimulation to improve pain and motor symptoms in Parkinson's disease.

BACKGROUND: In this study we analyze new clinical data in the use of spinal cord stimulation (SCS) for the treatment of pain and motor symptoms in patients with Parkinson's Disease (PD), as both a singular bioelectric therapy and as a salvage therapy after deep brain stimulation (DBS). METHODS: Fifteen patients were recruited and had percutaneous electrodes implanted at the level of the thoracic or cervical spine. Participants were set to one of three stimulation modes: continuous tonic stimulation, continuous Burst stimulation (40 Hz, 500 Hz, 1000 µs), or cycle mode (on time of 10-15 s, off time of 15-30 s) with Burst (40 Hz, 500 Hz, 1000 µs). Patients completed the Visual Analogue Scale (VAS), Unified Parkinson's Disease Rating Scale, Self-Rating Depression Scale, Hamilton Depression Rating Scale, Profile of Mood State, 10-meter walking test, and the Timed Up and Go (TUG). RESULTS: All patients experienced significant improvement in VAS scores with a mean reduction of 59% across all patients. Patients who chose the cycling burst stimulation parameter had an average 67% reduction in VAS scores, as compared to the continuous burst parameter group, which had an average 48% reduction in VAS scores. Seventy-three percent of patients experienced improvement in the 10-meter walk, with an average improvement of 12%. Sixty-four percent of patients experienced clinically relevant improvements in the TUG, with an average improvement of 21%. CONCLUSIONS: This study points to the potential utility of SCS to address both pain and certain aspects of motor symptoms in PD patients who have and have not received DBS therapy.

Cybersecurity Risks in a Pandemic.

Cybersecurity threats are estimated to cost the world US $6 trillion a year by 2021, and the number of attacks has increased five-fold after COVID-19. Although there is substantial literature on the threats technological vulnerabilities have on the health care industry, less research exists on how pandemics like COVID-19 are opportunistic for cybercriminals. This paper outlines why cyberattacks have been particularly problematic during COVID-19 and ways that health care industries can better protect patient data. The Office for Civil Rights has loosened enforcement of the Health Insurance Portability and Accountability Act, which, although useful in using new platforms like Zoom, has also loosened physical and technical safeguards to cyberattacks. This is especially problematic given that 90% of health care providers had already encountered data breaches. Companies must implement well-defined software upgrade procedures, should use secure networks like virtual local area networks, and conduct regular penetration tests of their systems. By understanding factors that make individuals, health care organizations, and employers more susceptible to cyberattacks, we can better prepare for the next pandemic.