Abstract Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: ...preliminary results from 3 ongoing studies. Objective To assess the efficacy and side effects of immersive virtual reality (VR) distraction analgesia, as well as patient factors associated with VR analgesic efficacy in burn patients who require passive range-of-motion (ROM) physical therapy (PT). Design Prospective, randomized, controlled, within-subject trials. Setting Regional level I burn center in a university-affiliated urban hospital. Participants Patients (age range, 6−65y) who required passive ROM PT in sessions lasting 3 to 15 minutes after cutaneous burn injury. Interventions Standard analgesic (opioid and/or benzodiazepine) care and standard analgesic care plus immersive VR distraction. Main Outcome Measure Self-reported subjective pain ratings (0 to 100 graphic rating scale). Results A total of 146 treatment comparisons were made in 88 subjects, 75% of whom were children ages 6 to 18 years. Compared with standard analgesic treatment alone, the addition of VR distraction resulted in significant reductions in subjective pain ratings for worst pain intensity (20% reduction), pain unpleasantness (26% reduction), and time spent thinking about pain (37% reduction). Subjects’ age, sex, ethnicity, size of initial burn injury, or duration of therapy session did not affect the analgesic effects of VR distraction. Nausea with the standard care plus VR distraction condition was infrequent (15%) and mild, with 85% of the subjects reporting no nausea. Children provided higher subjective reports of “presence” in the virtual environment and “realness” of the virtual environment than did adults, but age did not affect the analgesic effects of VR distraction. Conclusions When added to standard analgesic therapy, VR distraction provides a clinically meaningful degree of pain relief to burn patients undergoing passive ROM PT. Multiple patient factors do not appear to affect the analgesic effect. Immersive VR distraction is a safe and effective nonpharmacologic technique with which to provide adjunctive analgesia to facilitate patient participation in rehabilitation activities.
Background Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but ...the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission. Study Design This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group. Results Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 95% CI, 5.0−6.7 vs 5.0 95% CI, 4.7−5.3 days), more ICU days (4.5 95% CI, 3.2−5.8 vs 2.8 95% CI, 2.6−3.1 days), and increased probability of return to the operating room (10% 95% CI, 6−13% vs 5% 95% CI, 4−6%) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group. Conclusions AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.
Background Patients who screen positive for alcohol misuse on the Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C ≥5 points) have significantly increased postoperative ...complications. Severe alcohol misuse (AUDIT-C ≥9 points) is associated with increased postoperative health care use; however, little is known about the prevalence of alcohol misuse in demographic and clinical subgroups of surgical patients. Methods The prevalence of alcohol misuse was evaluated among 10,284 patients (9,771 men and 513 women) who underwent major noncardiac surgery in Veterans Affairs (VA) hospitals during the fiscal years 2004 to 2006 and completed the AUDIT-C. Sex-stratified analyses evaluated prevalence rates of alcohol misuse (AUDIT-C ≥5) and severe misuse (AUDIT-C ≥9) across demographic and clinical subgroups. Results Overall, 1,607 (16%) men and 24 (5%) women screened positive for alcohol misuse (AUDIT-C ≥5) in the year before operation, with 4% and 2% screening positive for severe misuse (AUDIT-C ≥9), respectively. Alcohol misuse was more common among men who were <60 years of age, divorced or separated, current smokers, or American Stoke Association class 1 or 2, and those with cirrhosis/hepatitis or substance use disorders. Among patients with alcohol misuse, 36% of men and 58% of women were American Society of Anesthesiologists class 1 or 2, and most did not have diagnoses that were commonly associated with alcohol misuse. Conclusion Alcohol misuse is relatively common in male surgical patients. Moreover, surgical patients undergoing operation who screen positive for alcohol misuse are often relatively healthy, without health problems that might alert providers to their alcohol misuse in the absence of screening.
The National Asthma Education and Prevention Program put forth guidance on how to measure asthma control. This guidance is flexible regarding how the impairment component of control is assessed.
To ...evaluate and compare 3 different National Asthma Education and Prevention Program-informed definitions of asthma control and to explore the strength of association between levels of asthma control and future control, asthma-related costs, and health-related quality-of-life utilities.
We used descriptive statistics, the weighted K statistic, and regression methods to compare 3 definitions in a large registry cohort and to explore associations with clinical and health economic outcomes.
We followed up 3,061 patients (> or = 12 years old) in a representative sample of severe or difficult-to-treat asthma. At baseline, 9.1%, 17.1%, or 33.5% of patients were considered well controlled depending on the definition. Lung function was not a component of the definition where 33.5% of patients were well controlled. Weighted K statistics comparing the baseline control definitions ranged from 0.36 to 0.67. The adjusted R2 statistic from the models predicting the future odds of being well controlled, mean asthma-related costs, and mean utilities did not yield consistent results for ranking the definitions of control.
Although all 3 control definitions were correlated with future control and health economic outcomes, there were striking differences in the descriptive results across the definitions, including the proportion of patients in each category of control. Differences among definitions of asthma control may lead to divergent research conclusions or treatment practices. We do not advocate for one particular definition, but we call for standardization of control definitions for specific uses.
Abstract The natural history of pain at the end of life is not well understood. The purpose of this study was to estimate the association between clinical and demographic characteristics and pain in ...persons who received hospice care in the United States. Data for this study were obtained from a national provider of hospice pharmacy services and included information about the hospice and person receiving hospice care, including geographic location, primary diagnoses, pain intensity, and opioid analgesic use. The data were collected from 2000 to 2004. Worst pain intensity during the previous 24 hours was assessed by the hospice nurse using a 0–10 numeric rating scale (0 = none, 10 = worst) at an average of 4.1 times per person during hospice care. Regression models were constructed to explain last and average pain scores using data from persons with at least two pain intensity scores. Hospice services were provided to 51,578 persons with at least two pain intensity scores. Of this cohort, 52% were female, 87.5% were Caucasian, and 66.4% had a primary diagnosis of cancer. The mean age at discharge or death was 73.8 years. Patient characteristics accounted for nearly one-third and nearly one-half of the variability in last and average pain scores, respectively. Severe pain on admission and frequency of pain reports were associated with less intense pain. Clinical and demographic characteristics contributed to identifying persons who had severe pain during their hospice admission. These data contribute to understanding pain in persons at the end of life.
Abstract Objectives We examined health care use in conjunction with primary prophylaxis use of colony stimulating factors (CSF) during patients' initial course of chemotherapy. Methods This ...retrospective cohort study identified adults aged 25 years and older with a diagnosis of breast, colorectal, or nonsmall cell lung cancer between 2002 and 2005 from the Western Washington Surveillance Epidemiology and End Results Puget Sound registry. We linked these records to health insurance claims from four payers representing 75% of those insured in the state. Claims records were used to determine chemotherapy regimen type, CSF use, febrile neutropenia occurrences, and supportive care. Chemotherapy regimens were categorized as conferring high, intermediate, or low risk of myelosuppression according to the National Comprehensive Cancer Network guidelines. CSF use was described as primary prophylaxis, other, or none. Antibiotics and antifungal and antiviral agents per National Comprehensive Cancer Network guidelines for supportive care for cancer infection were categorized using Healthcare Common Procedure Coding System and National Drug Code assignments. Results Use of CSF as primary prophylaxis is not significantly associated with a reduction in antibiotic use or inpatient or outpatient visits. Primary prophylactic CSF use was associated with less use of antiviral drugs. Conclusions CSF use is not associated with a reduction in health care use, with the exception of antiviral drug use. Given the expense associated with CSF use, pragmatic trials and additional research are needed to further assess the affects of CSF on health care use.
OBJECTIVES: To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals.
DESIGN: A prospective cohort study.
...SETTING: Four sites of the Established Populations for Epidemiologic Studies of the Elderly.
PARTICIPANTS: This study included 9,093 subjects (aged ≥65) who were not disabled in mobility or ADLs at baseline.
MEASUREMENTS: Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually.
RESULTS: At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI)=1.09–1.39) to develop mobility disability and 1.28 times as likely (95% CI=1.09–1.52) to develop ADL disability. Risk for incident mobility was increased with short‐ (hazard ratio (HR)=1.27, 95% CI=1.08–1.50) and long‐acting benzodiazepines (HR=1.20, 95% CI=1.03–1.39) and no use. Risk for ADL disability was greater with short‐ (HR=1.58, 95% CI=1.25–2.01) but not long‐acting (HR=1.11, 95% CI=0.89–1.39) agents than for no use.
CONCLUSION: Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short‐acting agents does not appear to confer any safety benefits over long‐acting agents.
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