Unique Breast Cancer Screening Disparities in a Safety-Net Health System.

INTRODUCTION: Breast cancer screening (BCS) disparities leave historically underserved groups more vulnerable to adverse outcomes. This study explores granular associations between BCS and patient sociodemographic factors in a large urban safety-net health system. METHODS: A retrospective review among female patients ages 50-74 within an urban safety-net health system was conducted in 2019. All patients had a primary care visit in the past 2 years. Multiple patient health and sociodemographic characteristics were reviewed, as well as provider gender and specialty. Bivariate analyses and multivariable logistic regression were performed in 2022. RESULTS: The BCS rate among 11,962 women was 69.7%. Over half of patients were non-White (63.6%) and had public insurance (72.3%). Patients with limited English proficiency made up 44.3% of the cohort. Compared to their sociodemographic counterparts, patients with White race, English proficiency, and Medicare insurance had the lowest rates of BCS. Serious mental illness and substance use disorder were associated with lower odds of BCS. In multivariable analysis, when using White race and English speakers as a reference, most other races (Black, Hispanic, and Other) and languages (Spanish, Portuguese, and Other) had significantly higher odds of screening ranging from 8% to 63% higher, except Asian race and Haitian Creole language. Female (versus male) and internal medicine-trained providers were associated with higher screening odds. CONCLUSIONS: Multiple unique variables contribute to BCS disparities, influenced by patient and health system factors. Defining and understanding the interplay of these variables can guide policymaking and identify avenues to improve BCS for vulnerable or traditionally under-resourced populations.

Colorectal cancer screening in a safety-net health system: The intersectional impact of race, ethnicity, language, and mental health.

Though rates of colorectal cancer (CRC) screening continue to improve with increased advocacy and awareness, there are numerous disparities that continue to be defined within different health systems and populations. We aimed to define associations between patients' socio-demographic characteristics and CRC screening in a well-resourced safety-net health system. A retrospective review was performed from 2018 to 2019 of patients between 50 and 75-years-old who had a primary care visit within the last two years. Numerous patient characteristics were extracted from the medical record, including self-reported race, self-reported ethnicity, insurance, preferred language, severe mental health diagnoses (SMHD), and substance use disorder (SUD). Multivariate logistic regression assessed characteristics associated with CRC screening. Of 22,145 included patients, 16,065 (72.5%) underwent CRC screening. <40% of the population was White or of North American/European ethnicity and 38% had limited English proficiency. Hispanic patients had the highest screening rate while White patients had the lowest among races (78.1% vs 68.5%, respectively). White patients had higher rates of SMHD and SUD (p < 0.001). In multivariable analysis, most other races (Black, Asian, and Hispanic), ethnicities, and languages had significantly higher odds of screening, ranging from 20% to 55% higher, when White, North American/European, English-speakers are used as reference. In a well-resourced safety-net health system, patients who were non-White, non-North American/European, and non-English-speaking, had higher odds of CRC screening. This data from a unique health system may better guide screening outreach and implementation strategies in historically under-resourced communities, leading to strategies for equitable colorectal cancer screening.

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery.

BACKGROUND: Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery. AREAS OF UNCERTAINTY: Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery. DATA SOURCES: Narrative literature review using keywords, expert opinion, either during or from live conference. THERAPEUTIC ADVANCES: Local and IA administration of NSAIDs for pain management in orthopedic surgery. CONCLUSION: There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

Perioperative bleeding and non-steroidal anti-inflammatory drugs: An evidence-based literature review, and current clinical appraisal.

Patient satisfaction measures and the opioid epidemic have highlighted the need for effective perioperative pain management. Multimodal analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs), have been shown to maximize pain relief and reduce opioid consumption, but are also associated with potential perioperative bleeding risks.A multidisciplinary panel conducted a clinical appraisal of bleeding risks associated with perioperative NSAID use. The appraisal consisted of review and assessment of the current published evidence related to the statement "In procedures with high bleeding risk, NSAIDs should always be avoided perioperatively." We report the presented literature and proceedings of the subsequent panel discussion and national pilot survey results. The authors' assessment of the statement based on current evidence was compared to the attempted national survey data, which revealed a wide range of opinions reflecting the ongoing debate around this issue in a small number of respondents.The appraisal concluded that caution is warranted with respect to perioperative use of NSAIDs. However, summarily excluding NSAIDs from perioperative use based on potential bleeding risks would be imprudent. It is recommended that NSAID use be guided by known patient- and procedure-specific factors to minimize bleeding risks while providing effective pain relief.

Current Perspective on the Use of Opioids in Perioperative Medicine: An Evidence-Based Literature Review, National Survey of 70,000 Physicians, and Multidisciplinary Clinical Appraisal.

Objective: Opioids represent an important analgesic option for physicians managing acute pain in surgical patients. Opioid management is not without its drawbacks, however, and current trends suggest that opioids might be overused in the United States. An expert panel was convened to conduct a clinical appraisal regarding the use of opioids in the perioperative setting. Methods: The clinical appraisal consisted of the review, presentation, and assessment of current published evidence as it relates to the statement "Opioids are not overused in the United States, even though opioid adjunct therapy achieves greater pain control with less risk." The authors' evaluation of this statement was also compared with the results of a national survey of surgeons and anesthesiologists in the United States. Results: We report the presented literature and proceedings of the panel discussion. The national survey revealed a wide range of opinions regarding opioid overuse in the United States. Current published evidence provides support for the efficacy of opioid therapy in surgical patients; however, it is not sufficient to conclude unequivocally that opioids are-or are not-overused in the management of acute surgical pain in the United States. Conclusions: Opioids remain a key component of multimodal perioperative analgesia, and strategic opioid use based on clinical considerations and patient-specific needs represents an opportunity to support improved postoperative outcomes and satisfaction. Future studies should focus on identifying optimal procedure-specific and patient-centered approaches to multimodal perioperative analgesia.

Defining new directions for more effective management of surgical pain in the United States: highlights of the inaugural Surgical Pain Congress™.

Despite advances in pharmacologic options for the management of surgical pain, there appears to have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however, is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is a clear unmet need for a national surgical pain management consensus task force to raise awareness and develop best practice guidelines for improving surgical pain management, patient safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress™ has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida) evaluated the current surgical pain management paradigm and identified key components of best practices.

When does testing for GERD become cost effective in an integrated health network?

BACKGROUND: Gastroesophageal reflux (GERD) is the most common gastrointestinal disorder, affecting as many as 14% of the US population. Rising rates of esophageal adenocarcinoma are seen in this population, and chronic proton pump inhibitor (PPI) use does not normalize cancer risk. It has also been demonstrated that up to one-third of patients on PPI therapy did not actually have GERD and could be taken off the medication. These facts form the basis for a quality-assurance study of care provided to patients in an integrated health care network who were on high-dose, long-term PPI therapy. METHODS: A cost-benefit analysis of patients who were on double-dose PPI therapy for more than 6 months was performed. Pharmacy, facility, physician reimbursement, and radiologic data from a cohort who were both primary-care patients and insured in our system were utilized. RESULTS: Two hundred and twenty-four patients were prescribed a double dose of this medication for over 6 months. Utilizing a 4.5% discount rate, our break-even analysis showed that Bravo testing [with esophagogastroduodenoscopy (EGD)] needed to identify those patients who could be taken off PPI therapy paid for itself in 33 months. Bravo + EGD + manometry testing needed to screen for other possible pathologies paid for itself in 38 months. Bravo + barium swallow + EGD testing to screen patients for possible esophageal adenocarcinoma paid for itself in 42 months. Bravo + barium swallow + manometry + EGD testing paid for itself in 47 months. CONCLUSIONS: Significant savings can be realized through early use of upper endoscopy, Bravo testing, barium swallow, and manometry to identify patients that are taking double-dose PPIs unnecessarily based on presumptive diagnosis of GERD. This early testing also has the potential to diagnose a variety of other clinically important pathologic conditions more readily.

Dispensing of fluticasone propionate/salmeterol combination in the summer and asthma-related outcomes in the fall.

BACKGROUND: Asthma exacerbations occur year-round; however, peak asthma-related events occur in the fall and are frequently associated with viral respiratory infections. OBJECTIVE: To compare the rates of asthma-related emergency department (ED) visits and hospitalizations in the fall (September, October, November) between users and nonusers of fluticasone propionate plus salmeterol in a single inhaler (FSC) in the preceding summer. METHODS: This was a retrospective, observational study using health care claims from a large managed care database. Patients age 4 to 55 years with both a medical claim for asthma and a pharmacy claim for FSC were categorized into 3 age groups: children (4-11 years), adolescents (12-18 years), and adults (19-55 years). RESULTS: There were 201,973 observations of FSC dispensings and 184,143 observations without FSC. Across all age groups, summertime dispensings of FSC were associated with a significantly lower (P < .001) risk of an asthma-related ED visit (4-11 years: adjusted odds ratio [OR], 0.54, 95% CI, 0.49-0.60; 12-18 years: OR, 0.59, 95% CI, 0.54-0.64; 19-55 years: OR, 0.53, 95% CI, 0.51-0.55) or hospitalization (4-11 years: OR, 0.43, 95% CI, 0.35-0.54; 12-18 years: OR, 0.49, 95% CI, 0.40-0.60; 19-55 years: OR, 0.61, 95% CI, 0.57-0.65) in the subsequent fall. This protective effect persisted even for patients with fall dispensings of FSC. The risk of oral corticosteroid dispensing in the fall was also significantly reduced in all age groups. CONCLUSION: Summertime dispensings of FSC were associated with a decreased risk of serious asthma-related outcomes in the subsequent fall. Continuous use of FSC before seasonal viral exposure may decrease seasonally related exacerbations.

Burden of allergic rhinitis: results from the Pediatric Allergies in America survey.

Allergic rhinitis (AR), a chronic inflammatory disease of the upper airway, is one of the most common chronic diseases in the United States and is estimated to affect up to 60 million people. Pediatric Allergies in America is the largest and most comprehensive survey to date of pediatric patients and parents of patients with allergy, as well as health care providers (HCPs), regarding AR in children and its treatment. The goals of the survey were to determine the prevalence of AR in the US pediatric population and to collect information on what effect the condition has on patients in terms of symptom burden, quality of life, productivity, disease management, and pharmacologic treatment. This national survey screened 35,757 households to identify 500 children with HCP-diagnosed nasal allergies and 504 children without nasal allergies who were between the ages of 4 and 17 years. Parents of young children, as well as children 10 to 17 years of age, were questioned about the condition and its treatment. In parallel, 501 HCPs were interviewed. This survey has captured previously unavailable data on the prevalence of nasal allergies and their most common and most bothersome symptoms, on the effect of nasal allergies on the quality of life of children, and on medication use, including both over-the-counter and prescription medications, and has identified factors affecting satisfaction with treatment. The Pediatric Allergies in America survey also identifies distinct areas for improvement in the management of AR in children. In fact, based on the results of this survey, it appears that HCPs overestimate patients' and parents' satisfaction with disease management and the benefit of medications used for the treatment of nasal allergies in children. Findings from this national survey have identified important challenges to the management of AR, suggesting that its burden on children in the United States has been significantly underestimated.

Choledochocele Presenting as Recurrent Pancreatitis.

We report the case of a 31-year-old male with recurrent episodes of acute pancreatitis, subsequently discovered to have a rare type III choledochal cyst, also termed a choledochocele. This case demonstrates the utility of multiple imaging techniques to diagnose the correct etiology of the patient's pancreatitis, as well as to appropriately plan surgical intervention. For many years, endoscopic retrograde cholangeopancreatography has been the gold-standard for diagnosis of type III choledochal cysts; this procedure, however, carries a significant degree of morbidity and may perhaps be circumvented with the advent of advanced imaging techniques that allow for visualization of the intraduodenal portion of the biliary tract. In this case, CT and MR imaging demonstrated a spherical, cyst-like structure extending from the pancreatic duct into the second part of the duodenum, suggestive of a choledochocele. Presence of the choledochocele and its exact anatomy were confirmed with ERCP. This imaging, in combination with the appropriate clinical constellation of symptoms, enabled correct identification of the etiology of the patient's unexplained recurrent episodes of pancreatitis, allowing for appropriate and curative surgical intervention.

Evaluating the safety of intranasal steroids in the treatment of allergic rhinitis.

: Given that intranasal corticosteroids (INCs) are widely considered first-line therapies for treatment of rhinitis, it is important for the clinician to be comfortable with the side-effect profile and be able to discuss potential safety concerns regarding these therapies. Among the safety concerns with the use of INCs are the potential for growth suppression both short and long term, the potential for hypothalamic-pituitary-adrenal axis suppression, ocular safety, and the use of INCs concomitantly with inhaled corticosteroids in asthma patients. As all clinicians are aware, each patient can have individual responses to both efficacy and safety; however, the data reviewed suggest that the benefits outweigh the potential risks. Understanding the potential concerns and the data behind these concerns should give clinicians the information to be able to discuss this with patients and parents to incorporate appropriate therapy for those with allergic rhinitis.

Real-world assessment of a metered-dose inhaler with integrated dose counter.

Currently available metered dose inhalers (MDIs) do not track the remaining number of doses, indicating the need for a device that accurately monitors medication use. In an open-label study at 37 outpatient centers, patients > or =4 years old with asthma or chronic obstructive pulmonary disease requiring short-acting 32-agonists received two actuations of albuterol hydrofluoroalkane (HFA) [Ventolin HFA: GlaxoSmithKline], 90 microg twice daily, via a novel MDI with an integrated dose counter until all 200 actuations were completed. Concordance between counter readings, diary card-recorded actuations, and canister weights were measured in patients who completed > or =90% of the labeled actuations (n = 224). Adverse events and patient satisfaction were assessed in the intent-to-treat population (n = 268). In 43,865 recorded actuations, 333 counter versus diary discrepancies occurred (discrepancy rate of 0.76%), and 88% of discrepancies were by one to two actuations. Forty-seven percent of patients had no discrepancies. Incidence of the device firing without changes in counter readings was very low (0.09%). Mean expected actuations based on canister weights (184) were slightly lower than mean counter and diary-reported actuations (200 each). At baseline, 62% of patients reported anxiety about not knowing the quantity of medication remaining in their inhaler. On study completion, 92% expressed satisfaction with the dose counter and 92% agreed it would help prevent them from running out of medication. The adverse event profile showed that albuterol HFA was well tolerated. Integrated MDI counters are a useful and reliable tool for tracking a patient's medication supply.

Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy.

BACKGROUND: Neoadjuvant chemoradiotherapy (neo-CRT) is being used with increasing frequency for periampullary tumors, but how it alters the complication rate of pancreaticoduodenectomy (PD) is unclear. METHODS: A retrospective analysis was conducted of 79 patients with periampullary malignancies who received 5-fluorouracil-based neo-CRT followed by PD. RESULTS: There was no difference in mortality between PD after neo-CRT (3.8%) and conventional PD for either malignant (4.5%) or benign (2.2%) disease. Focusing only on patients with malignancy, the neo-CRT group had a significantly lower pancreatic leak rate than the conventional group (10% vs. 43%; P < .001). Intra-abdominal abscesses were less common in the neo-CRT group (8.8% vs. 21%; P = .019), and there was one (1.2%) amylase-rich abscess in neo-CRT group, compared with eight (12%) in the conventional group. In addition, two patients in the conventional group died of leak-associated sepsis, compared with none in the neo-CRT group. Multivariate analysis revealed that neoadjuvant chemoradiation (odds ratio, .15) was the most significant factor associated with a reduced risk of pancreatic leak. CONCLUSIONS: Neo-CRT does not increase the mortality or morbidity of PD. In contrast, neo-CRT was associated with a marked reduction in the incidence of pancreatic leak, as well as leak-associated morbidity and mortality.

Management of hepatic metastases from colorectal cancer.

The majority of hepatic metastases in the United States occur in patients with a primary colorectal malignancy. Advances in technology combined with increasing surgeon experience have broadened the treatment options available for hepatic metastases from colorectal cancer. Surgical resection is the most effective therapy for metastatic colorectal cancer isolated to the liver. The aim of this article is to discuss the role of locally aggressive treatment options including resection, ablation, and regional chemotherapy in the management of patients with metastases from colorectal cancer.

Concurrent use of intranasal and orally inhaled fluticasone propionate does not affect hypothalamic-pituitary-adrenal-axis function.

Two double-blind, randomized, placebo-controlled, parallel group safety and efficacy studies included evaluation of the hypothalamic-pituitary-adrenal (HPA)-axis effects of concurrent treatment with intranasal and orally inhaled fluticasone propionate (FP). In the first study, patients with asthma who were > or =12 years of age were assigned randomly to receive twice-daily doses (either 88 or 220 microg) of orally inhaled FP delivered from a metered-dose inhaler (MDI). In the second study, patients were assigned randomly to receive either orally inhaled FP 250 microg or orally inhaled FP 250 microg/salmeterol 50 microg delivered via the Diskus device. In both studies, patients with rhinitis were allowed to continue the use of intranasal FP at their usual dosing. Treatment periods were 26 weeks and 12 weeks for the MDI and Diskus studies, respectively. HPA-axis effects were assessed using response to short cosyntropin stimulation testing. The number and percentage of patients with an abnormal cortisol response, defined as a morning plasma cortisol of <5 microg/dL, a poststimulation peak of <18 microg/dL, or a poststimulation rise of <7 microg/dL, were summarized in two subgroups: patients who used intranasal FP and those who did not. The concurrent administration of intranasal FP and orally inhaled FP via an MDI or Diskus or via Diskus with salmeterol was not associated with HPA-axis effects compared with orally inhaled FP alone. The results of these two studies suggest that concurrent use of intranasal FP with orally inhaled FP administered via MDI or Diskus for treatment of comorbid rhinitis and asthma does not increase the risk of HPA-axis abnormalities.

Patient perceptions of an inhaled asthma medication administered as an inhalation powder via the Diskus or as an inhalation aerosol via a metered-dose inhaler.

OBJECTIVE: To evaluate patient preference, ease of use, and correctness of use of fluticasone propionate administered as inhalation powder via the Diskus (GlaxoSmithKline, Research Triangle Park, NC) and as inhalation aerosol administered via metered-dose inhaler (MDI). METHODS: In 154 patients 12 years of age and older with asthma and a history of MDI use, the Diskus and the MDI were compared in a randomized, open-label, 7-week crossover study. RESULTS: In patients who had used both devices, more found the Diskus easier to use (59%) and preferred it overall (60%) compared with the MDI (P < or = 0.025). Ninety-eight percent (for the MDI) vs 91% (for the Diskus) of patients were able to correctly perform all the maneuvers necessary to use the devices correctly by either viewing a single demonstration and/or reading the instructions for use. Ninety-four percent of all patients found it easier to tell the number of residual doses with the Diskus (P < 0.001), and 59% of patients indicated that they would most likely request the Diskus from their physician (P = 0.025). Compliance was significantly better with the Diskus; 91.1% of patients used the Diskus as directed compared with 78.6% for the MDI (P = 0.013). CONCLUSIONS: In patients exposed to both devices, the majority preferred the Diskus and found it easier to use compared with the MDI. Ninety-one percent of patients used the Diskus correctly with minimal training, and when given a choice, most indicated they would likely request the Diskus from their physicians. Together, these data indicate a significant level of acceptance of the Diskus device in this patient population.

Activity-induced asthma.

Exercise is the most common trigger of persistent childhood asthma. The history for EIA can be complicated by the lack of perception of significant airway obstruction during exercise. One must carefully identify those children with EIA from the group of children who report low level of activity because of lack of interest or because they are out of shape. Baseline spirometry of children with persistent asthma is frequently normal. Spirometry is important to identify those children with EIA who underrecognize their disease, but normal results should not be used as evidence of absence of disease. Formal exercise testing should be considered when the diagnosis is unclear or if there seems to be a lack of bronchoprotection with inhaled albuterol. The goal of treatment of EIA should be the attainment of a normal activity level for children and adolescents. Identification of the limits imposed by EIA and establishment of goals of therapy with the child and family should be the initial action. Inactivity or reduced exertion, in the presence of this diagnosis. should not be accepted. Therapy for EIA starts with control of the underlying persistent asthma. Inhaled corticosteroids are the most effective initial treatment of both EIA and persistent asthma in children and adolescents. Exercise-induced asthma is a common aspect of a prevalent disease that warrants proper diagnosis and treatment. With appropriate therapy, children with EIA should be able to participate in sports and maintain normal activity. They should strive to compete in the same playing field as their peers and have the same goals as those children and athletes who do not have exercise-induced asthma.