"Nobody Knows How You're Supposed to Interpret it:" End-user Perspectives on Prescription Drug Monitoring Program in Massachusetts.

OBJECTIVES: America's overdose crisis spurred rapid expansion in the number and scope of prescription drug monitoring programs (PDMPs). As their public health impact remains contested, little is known about PDMP user experiences and perspectives. We explore perspectives of PDMP end-users in Massachusetts. METHODS: Between 2016 and 2017, we conducted semi-structured qualitative interviews on overdose crisis dynamics and PDMP experiences with a purposive sample of 18 stakeholders (prescribers, pharmacists, law enforcement, and public health regulators). Recordings were transcribed and double-coded using a grounded hermeneutic approach. RESULTS: Perspectives on prescription monitoring as an element of overdose crisis response differed across sectors, but narratives often critiqued PDMPs as poorly conceived to serve end-user needs. Respondents indicated that PDMP: (1) lacked clear orientation towards health promotion; (2) was not optimally configured or designed as a decision support tool, resulting in confusion over interpreting data to guide health care or law enforcement actions; and, (3) problematized communication and relationships between prescribers, pharmacists, and patients. CONCLUSIONS: User insights must inform design, programmatic, and policy reform to maximize PDMP benefits while minimizing harm.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence.

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

Hospital-Initiated Care Bundle, Posthospitalization Care, and Outcomes in Adults with Asthma Exacerbation.

BACKGROUND: Hospitalization for asthma exacerbation is an opportune setting for initiating preventive efforts. However, hospital-initiated preventive asthma care remains underdeveloped and its effectiveness is uncertain. OBJECTIVE: To examine the effectiveness of a hospital-initiated asthma care bundle on posthospitalization asthma care and clinical outcomes. METHODS: Prospective multicenter study of adults (18-54 years) hospitalized for asthma exacerbation in 2017 to 2019. During the hospitalization, we implemented an asthma-care bundle (inpatient laboratory testing, asthma education, and discharge care), and prospectively measured chronic asthma care (eg, immunoglobulin E testing, specialist care) and asthma exacerbation (ie, systemic corticosteroid use, emergency department [ED] visit, hospitalizations) outcomes. By applying a self-controlled case series method, we examined within-person changes in these outcomes before (2-year period) and after (1-year period) the bundle implementation. RESULTS: Of 103 adults hospitalized for asthma exacerbation, the median age was 40 years and 72% were female. Compared with the preimplementation period, the postimplementation period had improved posthospitalized asthma care, including serum specific immunoglobulin E testing (rate ratio [RR] 2.18; 95% confidence interval [95% CI] 0.99-4.84; P = .051) and evaluation by asthma specialist (RR 2.66; 95% CI 1.77-4.04; P < .001). Likewise, after care bundle implementation, patients had significantly lower annual rates of systemic corticosteroid use (4.2 vs 2.9 per person-year; RR 0.70; 95% CI 0.61-0.80; P < .001), ED visits (3.2 vs 2.7 per person-year; RR 0.83; 95% CI 0.72-0.95; P = .008), and hospitalizations (2.1 vs 1.8 per person-year; RR 0.82; 95% CI 0.69-0.97; P = .02). Stratified analyses by sex, race and ethnicity, and health insurance yielded consistent results. CONCLUSIONS: After hospital-initiated care bundle implementation, patients had improved posthospitalization care and reduced rates of asthma exacerbation.

Teaching Psychotherapy.

Although there is debate about the importance of a strong foundation in psychotherapy for psychiatrists, the literature provides ample evidence of the positive impact on patient care outcomes when psychiatrists are competent to provide this important form of treatment. Despite financial pressures and increases in managed care posing a threat to the maintenance of psychotherapy as a core skillset for psychiatrists, psychotherapy training should not only be maintained within psychiatry residency training but should in fact be given a renewed focus and priority within training programs.

Supportive Therapy in the Medically Ill: Using Psychiatric Skills to Enhance Primary Care.

Supportive therapy is a practical, flexible, and patient-centered psychosocial intervention that can help improve outcomes for patients struggling with a wide variety of medical illnesses. Due to its highly adaptable nature, brief supportive therapy can be practiced in busy clinical settings by consultation and liaison psychiatrists and primary care providers. In supportive therapy, the patient and provider work collaboratively to reduce distress and enhance functioning. The available evidence supports the use of supportive therapy techniques in managing the mental health consequences of medical conditions. This narrative review helps primary care providers learn and implement the basic goals and interventions of supportive therapy.

Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis.

BACKGROUND: Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS: A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS: Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION: Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.

The impact of transsphenoidal surgery on neurocognitive function: A systematic review.

BACKGROUND: Cognitive impairment following transsphenoidal surgery (TSS) among patients with pituitary tumors has been intermittently reported and is not well established. We performed a systematic review to summarize the impact of TSS on cognitive function. METHODS: We conducted a systematic search of the literature using the PubMed, Cochrane, and Embase databases through October 2014. Studies were selected if they reported cognitive status after surgery and included at least 10 adult patients with pituitary tumors undergoing either endoscopic or microscopic TSS. RESULTS: After removing 69 duplicates, 758 articles were identified, of which 24 were selected for full text review after screening titles and abstracts. After reviewing full texts, nine studies with a combined total of 682 patients were included in the final analysis. Eight studies were cross-sectional and one was longitudinal. These studies used a wide variety of neurocognitive tests to assess memory, attention and executive function post-operatively. Of the eight studies, six reported impairments in verbal and non-verbal memory post-operatively, while others found no association related to memory, and some reported an improvement in episodic, verbal, or logical memory. While four studies found an impaired association between TSS and attention or executive function, another four studies did not. CONCLUSION: The current literature on cognitive impairments after TSS is limited and inconsistent. This review demonstrates that patients undergoing TSS may experience a variety of effects on executive function and memory post-operatively, but changes in verbal memory are most common.