Association of Average Daily Morphine Milligram Equivalents and Falls in Older Adult Chronic Opioid Users.

Opioids remain commonly prescribed in older adults, despite the known association with falls and fall-related injuries. This retrospective cohort study sought to determine the association of opioid use and falls in older adult opioid users. Using a one-year lookback period in electronic health records, daily morphine milligram equivalents (MMEs) were calculated using prescription orders. Fall history was based on patient self-reporting. A receiver operating characteristic (ROC) curve was used to identify the threshold of average daily MMEs at which the likelihood of falls was increased. Older opioid users were most often women and White, with 30% having fallen in the prior year. In ROC analyses (n = 590), the threshold where fall risk increased was 37 MMEs (p = 0.07). Older adults prescribed more than 37 MMEs daily may be at increased fall risk and should be targeted for deprescribing interventions. Additionally, analysis on patient characteristics and covariates suggest that sex, age, COPD, sleep apnea, cancer, and psychiatric conditions may indicate an increased risk of falls in older adults taking chronic opioids (p < 0.05). Multifactorial interventions may be needed to modify fall risk beyond medication use alone.

Implementing the EXPEDITE parenteral induction protocol: Rapid parenteral treprostinil titration and transition to oral treprostinil.

Treprostinil is a prostacyclin analogue that targets multiple cellular receptors to treat pulmonary arterial hypertension (PAH). In certain scenarios, patients may require aggressive treprostinil titration. Several studies have demonstrated that higher doses of treprostinil lead to greater clinical benefit. Data supports successful transitions from parenteral to oral treprostinil; however, administration routes, transition duration, and transition setting vary in the real-world. The EXPEDITE clinical trial (NCT03497689) prospectively studied whether rapid parenteral treprostinil induction can be used to achieve high doses of oral treprostinil (total daily dose: ≥12 mg) in prostacyclin naïve PAH patients. Parenteral prostacyclin induction may be more appropriate for patients who need to reach therapeutic dosing more urgently than longer titration durations reported with conventional de novo oral treprostinil initiation. This summary provides strategies utilized in EXPEDITE. Parenteral treprostinil was initiated at 2 ng/kg/min intravenously or subcutaneously; clinicians determined the frequency and dose increment of up-titration. Two distinct transition schedules from parenteral to oral treprostinil were employed: rapid cross-titration in an inpatient setting (median: 2 days) or gradual cross-titration in an outpatient setting (median: 5 days). Patient status was closely monitored after transition; oral treprostinil dose was titrated to clinical effect and tolerability. Factors considered when individualizing dosing strategies included parenteral and oral treprostinil target doses, nursing support, patient education, medication counseling and adverse events management. EXPEDITE demonstrated the time to a therapeutic dose of oral treprostinil is significantly shorter when utilizing a short-term parenteral induction strategy and may be suitable for patients requiring aggressive titration of oral treprostinil.

Influence of a negative sestamibi scan on the decision for parathyroid operation by the endocrinologist and surgeon.

BACKGROUND: It has been observed that negative sestamibi scans may impact practice patterns in patients with primary hyperparathyroidism. However, there are no published data on the issue. The objective was to elucidate the influence of negative sestamibi scans on referrals by endocrinologists for parathyroidectomy and surgeon decision-making. METHODS: All patients with primary hyperparathyroidism were identified within a region-wide health care system over a 2-year period. Data, including age, calcium, parathyroid hormone, renal function, bone density, and sestamibi scan results, were collected from the electronic medical record of all patients. The electronic referral system was used to track consultations with endocrinologists and surgeons. Multivariable logistic regression analysis was done to model factors involved in endocrinologist recommendations (referral or no referral to operation) and surgeon recommendations (parathyroidectomy or no parathyroidectomy). RESULTS: A total of 539 patients with primary hyperparathyroidism were identified, and 452 were seen by endocrinologists. Of these, 260 patients had sestamibi scans done (120 negative and 140 positive), and 201 (77%) patients were referred to surgeons. Compared with positive sestamibi scans, negative sestamibi scans were independently associated with no referral to surgeons, after adjusting for presence of classic symptoms, age, fitness for operation, calcium, parathyroid hormone, glomerular filtration rate, and bone density (odds ratio = 0.36; 95% confidence interval 0.18-0.73). Surgeons saw an additional 54 patients referred from nonendocrinologists or primary care physicians and sestamibi scans were completed. Surgeons recommended parathyroidectomy in 236 of the 255 patients. Negative sestamibi scans were independently associated with no recommendation for operation (odds ratio = 0.32; 95% confidence interval 0.11-0.91). Surgeons initially scheduled and completed parathyroidectomies in 211/255 patients. Cure rate after operation was 98%, and this was not influenced by the sestamibi scan result. CONCLUSION: Negative sestamibi scans influence decision making in the management of patients with primary hyperparathyroidism. Endocrinologists commonly order sestamibi scans, and if negative, they are less likely to refer patients to surgeons. Surgeons are also influenced by sestamibi scans, and if negative, they are less likely to recommend parathyroidectomy. Cure rate in sestamibi-negative patients is excellent after operation.

Update on bariatric surgical procedures and an introduction to the implantable weight loss device: the Maestro Rechargeable System.

There are many different methods of treating obesity, ranging from various medical options to several surgical therapies. This paper briefly summarizes current surgical options for weight loss with a focus on one of the newest US Food and Drug Administration-approved devices for surgical weight loss therapy, the Maestro Rechargeable System. Also known as the vagal blocking for obesity control implantable device, this tool blocks vagal nerve activity to induce weight loss.

Gallstone pancreatitis without cholecystectomy.

IMPORTANCE: Current guidelines recommend that patients with an initial episode of gallstone pancreatitis receive cholecystectomy. However, for various reasons, many patients do not. OBJECTIVE: To determine the risk of developing recurrent gallstone pancreatitis in patients who never receive a cholecystectomy. DESIGN: Retrospective cohort study using electronic medical records. SETTING: Inpatient and outpatient. PATIENTS: All patients in Kaiser Permanente Southern California with a primary diagnosis of acute gallstone pancreatitis hospitalized from January 1, 1995, through December 31, 2010, with no previous diagnosis of gallstone pancreatitis documented in the medical record. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy and/or stent placement, or no intervention. MAIN OUTCOMES AND MEASURES: Recurrent acute pancreatitis. RESULTS: A total of 1119 patients were identified. The median age at diagnosis was 63 years. Among the patients, 802 received no intervention and 317 received ERCP. After a median follow-up of 2.3 years, the overall risk of recurrent pancreatitis was 14.6%; it was 8.2% and 17.1% in patients who had ERCP and no intervention, respectively (P < .001). The median time to recurrence was 11.3 and 10.1 months in the patients who had ERCP and no intervention, respectively. Kaplan-Meier estimates of recurrence for 1, 2, and 5 years in the ERCP group were 5.2%, 7.4%, and 11.1%, compared with 11.3%, 16.1%, and 22.7% in the no-intervention group (hazard ratio = 0.45; 95% CI, 0.30-0.69; P < .001). Charlson Comorbidity Index and intensive care unit stay were independently associated with recurrence, whereas age, sex, and admission Ranson score were not associated. CONCLUSIONS AND RELEVANCE: In patients who did not undergo cholecystectomy, the risk of recurrent pancreatitis is significant. Endoscopic retrograde cholangiopancreatography mitigates this risk and should be considered during initial hospitalization if cholecystectomy is not done.

Diverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review.

BACKGROUND: The clinical course of diverticular disease in immunosuppressed patients is widely believed to be more severe than in the general population. In this study we systematically reviewed the literature regarding the epidemiology and clinical course of diverticulitis in immunosuppressed patients. Our goal was to develop recommendations regarding the care of this group of patients. METHODS: Using PubMed and Web of Knowledge we systematically reviewed all studies published between 1970 and 2009 that analyzed the epidemiology, clinical manifestation, or outcomes of treatment of diverticulitis in immunosuppressed patients. Keywords of "transplantation," "corticosteroid," "HIV," "AIDS," and "chemotherapy" were used. RESULTS: Twenty-five studies met our inclusion criteria. All of these studies focused on the impact of diverticulitis in patients with transplants or on chronic corticosteroid therapy. The reported incidence of acute diverticulitis in these patients was approximately 1% (variable follow-up periods). Among patients with known diverticular disease the incidence was 8%. Mortality from acute diverticulitis in these patients was 23% when treated surgically and 56% when treated medically. Overall mortality was 25%. CONCLUSIONS: Our study summarizes evidence that patients with transplants or patients on chronic corticosteroid therapy 1) have a rate of acute diverticulitis that is higher than the baseline population and 2) a mortality rate with acute diverticulitis that is high. Further research is needed to define whether these risks constitute a mandate for screening and prophylactic sigmoid colectomy.