Chronic use of benzodiazepines: The problem that persists.

Though clinical guidelines and policies discourage the chronic prescribing of benzodiazepines, rates of prescribing have continued to rise in the United States with an estimated 65.9 million office visits per year made for this purpose. Quietly, we have become a nation on benzodiazepines. There are numerous reasons for this discrepancy between official recommendations on the one hand, and actual clinical practice on the other. Drawing from the literature, we argue that while patients and providers both shoulder some of the responsibility, they cannot be solely blamed. Rather, policies and guidelines regarding benzodiazepine prescribing have become out of touch with the clinical reality that benzodiazepines are now deeply entrenched in modern medicine. We propose that guidelines regarding benzodiazepines need to reconsider how to apply concepts such as harm reduction and other lessons learned in the opioid epidemic in order to help physicians manage this increasingly pressing problem affecting millions of Americans.

Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review.

BACKGROUND: The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine. METHODS: Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings. RESULTS: Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients. CONCLUSIONS: Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.

Characteristics of emergency department transfers for hand surgery consultation.

BACKGROUND: The purpose of this study was to establish the characteristics of patients who are transferred from referring emergency departments (EDs) to two receiving institutions for hand-related emergencies. Our primary hypothesis was that many transferred patients would not require emergent specialty intervention. Our secondary hypotheses were that treatment would differ by day of presentation and type of insurance coverage. METHODS: We searched ED records for all hand-related cases over 1 year. We reviewed charts for demographics and treatment details. The main outcome measures were whether patients were seen by a hand surgeon or underwent surgery within 24 h of transfer. RESULTS: The study group comprised 296 patients. Ninety-two percent saw a specialty resident, and 48 % saw a hand surgeon. Thirty-nine percent of patients were taken to the operating room within 24 h of presentation. Of patients transferred on the weekends, 48 % saw a hand surgeon versus 61 % of those transferred on weekdays. Similarly, 51 % of patients transferred on a weekday were taken to the OR within 24 h, while 38 % of patients transferred on a weekend were taken to the OR in the same time frame. CONCLUSIONS: More than half of transfers for hand emergencies did not result in examination by a hand surgeon, and nearly two thirds did not require a visit to the OR within 24 h. Patients transferred on the weekend were less likely to see a hand surgeon than those transferred on weekdays. Alternative methods of consultation might allow avoidance of transfer.

Outcomes of open carpal tunnel release at a minimum of ten years.

BACKGROUND: There is little research on the long-term outcomes of open carpal tunnel release. The purpose of this retrospective study was to determine the functional and symptomatic outcomes of patients at a minimum of ten years postoperatively. METHODS: Two hundred and eleven patients underwent open carpal tunnel release from 1996 to 2000 performed by the same hand fellowship-trained surgeon. Follow-up with validated self-administered questionnaire instruments was conducted an average of thirteen years after surgery. The principal outcomes included the Levine-Katz symptom and function scores, ranging from 1 point (best) to 5 points (worst), and satisfaction with the results of surgery. The patients self-reported current comorbidities. RESULTS: After a mean follow-up of thirteen years (range, eleven to seventeen years), 92% (194) of 211 patients were located. They included 140 who were still living and fifty-four who had died. Seventy-two percent (113) of the 157 located, surviving patients responded to the questionnaire. The mean Levine-Katz symptom score (and standard deviation) was 1.3 ± 0.5 points, and 13% of patients had a poor symptom score (≥2 points). The mean Levine-Katz function score was 1.6 ± 0.8 points, and 26% had a poor function score (≥2 points). The most common symptom-related complaint was weakness in the hand, followed by diurnal pain, numbness, and tingling. The least common symptoms were nocturnal pain and tenderness at the incision. Eighty-eight percent of the patients were either completely satisfied or very satisfied with the surgery. Seventy-four percent reported their symptoms to be completely resolved. Thirty-three percent of men were classified as having poor function compared with 23% of women. Two (1.8%) of 113 patients underwent repeat surgery. CONCLUSIONS: At an average of thirteen years after open carpal tunnel release, the majority of patients are satisfied and free of symptoms of carpal tunnel syndrome.

Finding orthopedic patients lost to follow-up for long-term outcomes research using the Internet: an update for 2012.

The Internet is available to researchers as a tool for studying long-term outcomes, but no recent research exists on how to best use it. The authors hypothesize that using the Internet can be at least 75% effective in locating patients lost to follow-up. With Institutional Review Board approval, the authors searched for 66 patients lost to follow-up after a period of 10 years or more with no contact. They tested an Internet searching protocol developed in 2004 and developed an alternate protocol. In all, 74% (49/66) of patients were located.