Pregnancy Outcomes and Documentation Status Among Latina Women: A Systematic Review.

Purpose: The impression that Latinas experience paradoxically good pregnancy outcomes in the United States persists, despite evidence showing that these outcomes are not enjoyed by all Latina subgroups. We conducted this systematic literature review to examine the relationship between documentation status and pregnancy outcomes among Latinas. Methods: This review synthesizes empirical evidence on this relationship; examines how these studies define and operationalize documentation status; and makes recommendations of how a more comprehensive methodological approach can guide public health research on the impact of documentation status on Latina immigrants to the United States. We searched the literature within PubMed, Web of Science, Academic Search Premier, and Google Scholar in 2017 for relevant studies. Results: Based on stringent inclusion criteria, we retained nine studies for analysis. Conclusion: We found that evidence for the impact of documentation status on pregnancy outcomes among Latinas is not conclusive. We believe the divergence in our findings is, in part, due to variation in: conceptualization of how documentation status impacts pregnancy outcomes, sample populations, definitions of exposures and outcomes, and contextual factors included in models. Specific analytic challenges around sampling, measurement, and data analysis are identified. Suggestions for future research are offered regarding measurement of documentation status. Findings highlight the need for increased attention to documentation as an influence on Latina pregnancy outcomes.

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe-A Qualitative Study on the Decisionmaking Process of Emergency Department Providers.

STUDY OBJECTIVE: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. METHODS: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. RESULTS: Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. CONCLUSION: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

An Individualized Approach to Treatment-Resistant Bipolar Disorder: A Case Series.

CONTEXT: Treatment-resistant bipolar disorder (TRBD) is an increasingly prevalent, debilitating condition with substandard treatment outcomes. Polypharmacy has become the mainstay among practitioners though long-term efficacy of this method has not been adequately tested. OBJECTIVE: Determine retrospectively if individualized, integrative treatment strategies applied while withdrawing pharmaceuticals were beneficial and safe among a TRBD clinic population. DESIGN: A chart review was performed for six adult patients, treated in a private psychiatric practice. Data were collected regarding psychiatric diagnosis, hospitalizations, medications, side effects, substance abuse, and applied treatments. RESULTS: Using individualized, integrative psychiatric treatment methods, the majority of medications were eliminated. Long-term remission was attained in all cases, defined as clinical stability with no discernable symptoms of bipolar disorder for at least one year. CONCLUSIONS: Applying an integrative treatment approach, and eliminating most medications, provided lasting resolution of symptoms and side effects in a selected sample of TRBD outpatients. These data may provide the basis for future randomized, controlled trials.

Medication-free Alternatives for Long-term Maintenance of Bipolar Disorder: A Case Series.

Psychopharmacological treatment has been the mainstay in long-term maintenance of bipolar disorder (BD) patients for the last 60 years. Conventionally accepted treatment options are primarily based on expert opinion rather than on well-executed, independently funded research. Investigation of maintaining patients without medications using treatment alternatives has been neglected. This clinical case series examines the outcomes of 7 BD patients who experienced a poor response or significant side effects with conventional treatment modalities. Patients were gradually and safely withdrawn from all medications. Treatment strategies were based on an individualized holistic approach using herbs, nutritional supplements, vitamins, amino acids, acupuncture, dietary recommendations, and behavioral modifications. Multiple treatment modalities were combined addressing the etiological causes for BD symptoms. Upon withdrawal from psychotropic medications, patients were free of medication-induced side effects and obtained psychiatric stability for at least 10 months. Further research is needed to investigate the long-term outcomes of BD treatment modalities based on well-defined successful outcome criteria, such as reduction in symptoms, improvement in quality of life, overall health outcomes, and cost effectiveness.

El tratamiento psicofarmacológico ha sido el pilar fundamental en el mantenimiento a largo plazo de los pacientes con trastorno bipolar durante los últimos 60 años. Las opciones terapéuticas aceptadas convencionalmente se basan principalmente en la opinión de los expertos y no en investigaciones bien realizadas y financiadas de forma independiente. La investigación del mantenimiento de pacientes sin medicamentos usando tratamientos alternativos no ha recibido mucha atención. Esta serie de casos clínicos examina los resultados de 7 pacientes con trastorno bipolar que experimentaron una respuesta escasa o efectos secundarios significativos con modalidades de tratamiento convencionales. A los pacientes se les retiró toda la medicación de forma gradual y segura. Las estrategias terapéuticas se basaron en un enfoque individual holístico, utilizando productos de herboristería, suplementos nutricionales, vitaminas, aminoácidos, acupuntura, recomendaciones dietéticas y modificaciones del comportamiento. Se combinaron múltiples modalidades terapéuticas para abordar las causas etiológicas de los síntomas de trastorno bipolar. Tras la retirada de la medicación psicotrópica, los pacientes no tenían efectos secundarios inducidos por los fármacos y habían conseguido estabilidad psiquiátrica durante al menos 10 meses. Es necesaria más investigación para averiguar los resultados a largo plazo de las modalidades terapéuticas del trastorno bipolar basados en criterios de resultados positivos bien definidos, tales como la reducción de los síntomas, la mejora de la calidad de vida, los resultados generales de salud, y la rentabilidad.