Incorporating Social Determinants of Health into Patient Care Workflows Within a Health System Specialty Pharmacy.

BACKGROUND: The influence of adverse factors on social determinants of health (SDOH) and their impact on patient outcomes is widely recognized. Pharmacists, as accessible healthcare professionals, can play a pivotal role in identifying and addressing SDOH concerns. Health system specialty pharmacies have consistently assisted patients in accessing expensive specialty medications and ensuring adherence to therapy. As such, they are uniquely positioned to address SDOH concerns of patients. OBJECTIVE: To assess the effectiveness of incorporating standardized SDOH screening and referral methods into the patient care workflows of a health-system specialty pharmacy. PRACTICE DESCRIPTION: The University of North Carolina Health Care (UNC Health) Specialty and Home Delivery Pharmacy is a health-system owned specialty pharmacy serving patients in North Carolina, South Carolina, and Virginia. It holds accreditations from the Utilization Review Accreditation Commission and Accreditation Commission for Health Care. PRACTICE INNOVATION: A standardized SDOH screening and referral method was integrated into patient care workflows of a health-system specialty pharmacy. If SDOH concerns were identified upon screening by a specialty pharmacist, patients were referred to an entity within the health system responsible for connecting patients to local community resources to address their SDOH concerns. EVALUATION METHODS: The types of SDOH concerns, frequency of SDOH referrals, referral turnaround time, outcomes of the referrals, and patient demographics were evaluated to determine the impact of this project. Descriptive statistics were used to analyze results. RESULTS: Sixty-nine patients were included (female: n=38, 55.1%; age (mean±SD: 48.9±16.3). Eighty-seven SDOH concerns were reported, 54 patients (78.3%) were connected to local resources upon referral, and the average turnaround time of referrals was 2.2 business days. CONCLUSION: The findings of this pilot study highlight the effectiveness of incorporating SDOH screening and referral methods into specialty pharmacy workflows. Specialty pharmacies can successfully identify and address non-medical factors impacting patients.

Multilevel posterior spinal fusion following percutaneous third generation kyphoplasty complicated by vertebral compression fracture progression.

Newer third generation percutaneous kyphoplasty (PKs) may minimize risks associated with older generation kyphoplasties such as new adjacent fractures, fracture progression, cement leakage, neurologic sequelae, and kyphosis. Additionally, posterior pedicle spinal fusion (PPSF) may minimize risk of long-term complications following PKs while maximizing the benefits of stable spinal alignment. The patient developed adjacent fracture progression, posterior retropulsion, and kyphosis following third generation kyphoplasty. Vertebral compression fracture progression was corrected and prolonged symptomatic relief was successfully achieved with T11-L4 PPSF and L1-L2 laminectomy. Postoperative follow-ups at 2, 4, 7 weeks, 1 and 2 years showed continued symptomatic improvement in back pain with resolution of thigh and groin pain. This case supports the use of PPSF in third generation PK-related complications to provide long-term symptom relief and improve quality of life in patients with severe osteoporotic compression fractures.

Robotic-Assisted Versus Fluoroscopic-Guided Surgery on the Accuracy of Spine Pedicle Screw Placement: A Systematic Review and Meta-Analysis.

Spinal fusion is a common method by which surgeons decrease instability and deformity of the spinal segment targeted. Pedicle screws are vital tools in fusion surgeries and advancements in technology have introduced several modalities of screw placement. Our objective was to evaluate the accuracy of pedicle screw placement in robot-assisted (RA) versus fluoroscopic-guided (FG) techniques. The PubMed and Cochrane Library databases were systematically reviewed from January 2007 through to August 8, 2022, to identify relevant studies. The accuracy of pedicle screw placement was determined using the Gertzbein-Robbins (GR) classification system. Facet joint violation (FJV), total case radiation dosage, total case radiation time, total operating room (OR) time, and total case blood loss were collected. Twenty-one articles fulfilled the inclusion criteria. Successful screw accuracy (GR Grade A or B) was found to be 1.02 (95% confidence interval: 1.01 - 1.04) times more likely with the RA technique. In defining accuracy solely based on the GR Grade A criteria, screws placed with RA were 1.10 (95% confidence interval: 1.06 - 1.15) times more likely to be accurate. There was no significant difference between the two techniques with respect to blood loss (Hedges' g: 1.16, 95% confidence interval: -0.75 to 3.06) or case radiation time (Hedges' g: -0.34, 95% CI: -1.22 to 0.53). FG techniques were associated with shorter operating room times (Hedges' g: -1.03, 95% confidence interval: -1.76 to -0.31), and higher case radiation dosage (Hedges' g: 1.61, 95% confidence interval: 1.11 to 2.10). This review suggests that RA may slightly increase pedicle screw accuracy and decrease per-case radiation dosage compared to FG techniques. However, total operating times for RA cases are greater than those for FG cases.

Interventional Therapy and Surgical Management of Lumbar Disc Herniation in Spine Surgery: A Narrative Review.

Significant advancements in lumbar disc herniation (LDH) management have been made in interventional pain therapy, operative therapy, peri-operative management, and cost analysis of various procedures. The present review aims to provide a concise narrative of all these topics, current trends, and possible future directions in the management of LDH. Interventional pain management using intradiscal injections often serves as a minimally invasive non-surgical approach. Surgical modalities vary, including traditional open laminectomy, microdiscectomy, endoscopic discectomy, tubular discectomy, percutaneous laser disc decompression, and transforaminal foraminotomy. Prevention of infections during surgery is paramount and is often done via a single-dose preoperative antibiotic prophylaxis. Recurrence of LDH post-surgery is commonly observed and thus mitigative strategies for prevention have been proposed including the use of annular closure devices. Finally, all treatments are well-associated with clear as well as hidden costs to the health system and society as described by billing codes and loss of patients' quality-adjusted life-years. Our summary of recent literature regarding LDH may allow physicians to employ up-to-date evidence-based practice in clinical settings and can help drive future advancements in LDH management. Future longitudinal and comprehensive studies elucidating how each type of treatments fare against different types of herniations are warranted.

A detailed examination of reporting procedural fidelity in the Journal of Applied Behavior Analysis.

Few reviews on procedural fidelity-the degree to which procedures are implemented as designed-provide details to gauge the quality of fidelity reporting in behavior-analytic research. This review focused on experiments in the Journal of Applied Behavior Analysis (2006-2021) with "integrity" or "fidelity" in the abstract or body. When fidelity data were collected, the coders characterized measurement details (e.g., description of calculation, report of single or multiple values, frequency of fidelity checks, checklist use). The researchers found increasing trends in describing the calculation(s), reporting multiple values, and stating the frequency of measurement. Few studies described using a checklist. Most studies reported fidelity as a percentage, with high obtained values (M = 97%). When not collecting fidelity data was stated as a limitation, authors were unlikely to provide a rationale for the omission. We discuss recommendations for reporting procedural fidelity to increase the quality of and transparency in behavior-analytic research.

Trends in Reporting Procedural Integrity: A Comparison.

Procedural integrity refers to the extent to which an independent variable is implemented as described. Measuring procedural integrity is one important factor when considering internal and external validity of experiments. Experimental articles in behavior-analytic journals have rarely reported procedural-integrity data. The purpose of this study was to update previous reviews of whether articles published in the Journal of Applied Behavior Analysis reported procedural integrity, spanning a period from 1980 to 2020, and compare reporting in JABA to recent reviews of studies published in Behavior Analysis in Practice (2008-2019) and the Journal of Organizational Behavior Management (2000-2020). Procedural integrity continues to be underreported across all three journals, but an increasing trend in reporting procedural integrity is evident in the Journal of Applied Behavior Analysis and Behavior Analysis in Practice. In addition to our recommendations and implications for research and practice, we provide examples and resources to assist researchers and practitioners with recording and reporting integrity data.

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment.

Importance: The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population. Objective: This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period. Evidence Acquisition: First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE. Results: Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies. Conclusions and Relevance: Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.

Effects of angiotensin II in the management of perioperative hypotension in kidney transplant recipients.

BACKGROUND: Due to the mechanisms of action of conventional catecholamine vasopressors, there is increased risk of renal allograft injury and adverse events in transplant recipients with fluid-refractory distributive shock during the perioperative period. As such, mechanistically alternative vasopressors like angiotensin II (ATII) may avoid these complications, but there is an absence of data supporting use in this population. METHODS: This was a single-center, single-arm, open-label, phase 4 study conducted as a 1-year pilot of 20 adult renal transplant recipients receiving ATII as their first continuous infusion vasopressor in the perioperative period. The study aim was to systematically assess the safety and hemodynamic effects of ATII. Safety was assessed based on the incidence of adverse events. Hemodynamic effect was assessed by the achievement of per protocol hemodynamic goals (i.e., SBP ≥120 mmHg) and the need for adjunct vasopressors. RESULTS: Most cases involved deceased donors (70%), with a corresponding mean (SD) cold ischemia time of 14.7 (8.6) h. Over a surgery duration of 5.3 (1.2) h, subjects received 3.2 (2.0) L of total volume resuscitation prior to ATII initiation. No adverse events were directly related to ATII administration. Throughout this period, ATII was utilized for a median of 1.0 (IQR, 1.5) h intraoperatively (N = 7), 26.5 (IQR, 84.8) h postoperatively (N = 4), and 63.8 (IQR, 57.8) h in subjects who required ATII both intra- and postoperatively (N = 9). Only one of the 20 patients needed adjunct continuous infusion vasopressors in addition to ATII. CONCLUSIONS: Based on the observations of this pilot study, ATII is a safe and effective vasopressor option for renal transplant recipients requiring perioperative hypotension reversal.

Lower Urinary Tract Symptoms in Young Men-Causes and Management.

PURPOSE OF REVIEW: This review explores the subject of lower urinary tract symptoms (LUTS) in young men. RECENT FINDINGS: Young men (aged 39 or younger) can be affected by a variety of conditions that can cause LUTS. Approximately half of young men report LUTS. Storage or "irritative" voiding symptoms are nearly twice as common as "obstructive" symptoms in young men. Infectious or inflammatory causes such as prostatitis are the most common cause of LUTS in this age group, while other etiologies include urethral strictures, primary bladder neck obstruction, as well as neurogenic and non-neurogenic bladder dysfunction. A thorough clinical evaluation is critical for determining the correct diagnosis and directing the appropriate treatment plan. Young men experience lower urinary tract symptoms at relatively high rates. Clinical treatments range from behavioral therapy to medications and/or surgical interventions. Ambulatory urodynamics and wearable sensors may provide more accurate and real-world diagnostic assessment of bladder dysfunction in this relatively under-studied group. More study is needed to characterize the disease burden and impact in this specific group of patients.

Incidence of Significant Findings of Microhematuria Workup in Women-What Guidelines Work Best?

OBJECTIVE: To apply the American Urogynecological Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) recommendations of foregoing workup in patients under 50 years of age with less than 25 red cells per high-powered field, to a cohort of asymptomatic microscopic hematuria (AMH) patients, and assess diagnostic accuracy, sensitivity, specificity, positive, and negative predictive value compared to the American Urologic Association (AUA) guidelines. METHODS: Retrospective review of female patients who underwent AMH evaluation from 2012 to 2015. The number of patients who would have avoided workup following the AUGS/ACOG recommendations was determined. Sensitivity, specificity, positive- and negative-predictive value and accuracy of the AUGS/ACOG recommendations compared to AUA guidelines were determined. RESULTS: Six hundred twenty women underwent AMH workup with 265 women undergoing full workup as per the AUA guidelines. Applying the AUGS/ACOG recommendations to this cohort would not have resulted in missed malignant diagnoses. Two tumors were found, both in patients who had undergone complete workup, and for whom AUGS/ACOG recommends workup. Following the AUGS/ACOG recommendations would have avoided workup in 126/620 of all women and 44/265 women who underwent the full AUA workup. In looking at findings of malignancy, the AUGS/ACOG workup had a sensitivity of 100% and a negative predictive value of 100% as compared to the AUA guidelines. CONCLUSION: AUA guidelines may over screen female low risk AMH patients. Extensive workup in a low risk group of female patients does not result in increased cancer diagnoses. Perhaps a more nuanced approach could result in fewer workups without compromising cancer detection.

Use of a Risk Stratification Tool to Guide Evaluation of Patients With Asymptomatic Microscopic Hematuria.

OBJECTIVE: To determine if use of the hematuria risk index can reduce testing and cost, while maintaining equivalent lesion detection in patients with asymptomatic microscopic hematuria. MATERIALS AND METHODS: Retrospective cohort study of 1049 patients at single institution. Hematuria risk index score was calculated based on clinical factors including age, sex, smoking history, and degree of hematuria for each patient along with evaluation studies performed and total number of tumors discovered. Cost benefit analysis was performed based on published Medicare averages. RESULTS: Tumor detection rate in overall, low-risk, and moderate-risk groups were 1.2%, 0%, and 2.96% at a total cost of $408,376. When low-risk group is not screened cost decreases to $166,252 with no lesions missed. The cost to discover one lesion/cancer in the overall group was $34,031.3, the cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. Ultrasound may be utilized instead of computed tomography with minimal loss of lesion detection in select moderate risk patients. CONCLUSION: None of the low-risk hematuria risk patients were diagnosed with any lesions, as such these patients may not need an evaluation. Furthermore, by utilizing a risk-stratified approach to the assessment of asymptomatic microscopic hematuria health care costs can be significantly decreased with limited negative consequences in terms of lesion detection.

Outcomes and Complications After Intervention for Postradiation Prostatic Urethral Stenosis.

OBJECTIVE: To study and report on treatment outcomes after surgical intervention for postradiation prostatic urethral stenosis. METHODS: A retrospective chart review was performed, identifying all patients treated at our institution from July 2014-June 2018 with the ICD-10 code N42.89 for prostatic urethral stenosis. RESULTS: Twenty-two patients were identified with the diagnosis of prostatic urethral stenosis. Patients who had less than 3 months of follow up or etiologies other than postradiation were excluded from analysis. 16 patients were included in the final analysis with an average follow up of 2.6 years (range 3 months to 6.8 years). Average age was 74 years (range 63-84). The average number of interventions performed before referral to a reconstructive urologist was 2.2 (range 0-6). Following referral, an additional 1.2 procedures were performed. Transurethral resection of prostate was the most common intervention, performed in 11 patients; urethroplasty was performed in 2 and the remainder underwent endoscopic incision or dilation. None of the urethroplasty patients required any further intervention for recurrent stenosis. Five patients became severely incontinent and required placement of an artificial urinary sphincter. CONCLUSION: Prostatic urethral stenosis is a rare complication occurring after radiotherapy for prostate cancer. Endoscopic management can be successful in stabilizing patients, while urethroplasty can be feasibly performed in patients with short prostatic apical strictures.

Practice Patterns of Academic Urologists for Evaluating Microscopic Hematuria-How Well are We Following the Guidelines?

INTRODUCTION: Asymptomatic microscopic hematuria is a common clinical entity that may portend significant urinary tract disease. Guidelines vary in how asymptomatic microscopic hematuria should be evaluated, with the AUA (American Urological Association) guidelines arguably being the most comprehensive. We evaluated the practice patterns of academic urologists with respect to the 2012 AUA asymptomatic microscopic hematuria guidelines. METHODS: Records of patients who underwent evaluation for asymptomatic microscopic hematuria between 2012 and 2015 were retrospectively examined. The use of imaging, cystoscopy and urine cytology was analyzed. Factors such as age, gender, smoking status, history of nonurological malignancy, history of pelvic irradiation, presence of irritative voiding symptoms, use of anticoagulation, number of red blood cells on microscopic urinalysis and evaluation by an oncology fellowship trained urologist were assessed. Multivariable logistic regression analysis was performed to explore the association between patient or physician factors and adherence to the AUA guidelines. RESULTS: Among 1,049 patients with asymptomatic microscopic hematuria 247 (23.5%) were evaluated in complete accordance with AUA guidelines. Rates of adherence to the guidelines regarding imaging, cytology and cystoscopy were 48.2%, 54.2% and 72.5%, respectively. Much of nonadherence was due to lack of cross-sectional imaging (46.4%) and excessive use of urine cytology (45.8%). Guideline adherence was independently associated with smoking history, irritative voiding symptoms, history of nonurological malignancy and evaluation by a nononcology trained urologist. CONCLUSIONS: Overall adherence of urologists to the AUA asymptomatic microscopic hematuria guidelines was suboptimal. Efforts in limiting the use of urine cytology to high risk patients may be the most effective way of improving adherence.