We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI).
A total of 4 461 208 veterans ...were seen in the Veterans Health Administration's patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement.
A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes.
Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.
Background
The aim of this study was to assess the safety and efficacy of large balloon sphincteroplasty when used in conjunction with endoscopic biliary sphincterotomy during endoscopic retrograde ...cholangiopancreatography (ERCP) for therapy of choledocholithiasis.
Methods
A retrospective audit of all ERCP's performed for choledocholithiasis between January 2012 and October 2013 at one institution was performed. Procedures that utilized large balloon sphincteroplasty were compared with those underwent standard endoscopic stone extraction. Outcomes including stone clearance rate for the individual procedure type, post‐ERCP complications and need for surgical exploration of the bile duct were documented.
Results
A total of 346 procedures on 306 patients that met the inclusion criteria were identified. Fifty‐four (15.6%) procedures included large balloon sphincteroplasty and were compared with 292 (84.4%) procedures that used standard balloon extraction techniques. Despite those patients in the large balloon sphincteroplasty group having a higher rate of previous ERCP (33.3% versus 19.5%, P = 0.031) and a larger proportion of patients with stones greater than 10 mm (40.3% versus 11.3%, P < 0.001), the overall initial clearance rate was similar at 83%. Ultimately, only 14 out of 306 (4.6%) of all patients required surgical intervention. There was no significant difference in the rate of post‐ERCP pancreatitis between the two groups (5.6% versus 3.8%, P = 0.466).
Conclusion
Large balloon sphincteroplasty of the sphincter of Oddi is a safe and effective adjunct to endoscopic biliary sphincterotomy in difficult to treat choledocholithiasis. The current study demonstrated large balloon sphincteroplasty did not result in more complications despite a tendency to being used for larger stones.
The adoption of pharmacotherapies for the treatment of alcohol and drug use disorders has progressed slowly despite the approval of new and effective medications. This paper begins with overviews of ...the prevalence of alcohol and drug abuse and dependence, the costs of addiction to the nation, and the value of treatment services. The role of pharmacotherapy in the treatment of addictive diseases is examined, and factors that affect the adoption and use of medications for alcohol and drug treatment are identified and discussed. Investigations that tested the effectiveness of buprenorphine for treatment of opioid dependence in new settings illustrate physician and counselor training and mentorship strategies that may promote the adoption of medications in the treatment of alcohol and drug use disorders. The paper concludes with a discussion of barriers and ways to surmount the barriers and to foster greater use of medications in alcohol and drug treatment.
We report the rapid, one-pot synthesis of functional polycarbonates derived from renewable alcohols (i.e., glucose tetraacetate, acetyl isosorbide, lauryl alcohol, and ethanol) and a cyclic carbonate ...bearing an imidazolecarboxylate. This tandem functionalization/ring-opening polymerization strategy can be performed on multigram scale and eliminates the need for rigorous purification and specialized equipment. A wide range of glass transition temperatures (T g) was accessible from these renewable pendant groups (>75 °C T g window). We also synthesized several statistical copolycarbonates to show the thermal properties can be tailored with this tandem method. Additionally, we demonstrate a circular polymer economy via chemical recycling to a cyclic carbonate precursor. This work may facilitate development of sustainable polycarbonates with tailored properties that work toward eliminating plastic waste streams.
Opioids and benzodiazepines are commonly coprescribed medications. The mortality risk associated with their concurrent use is unknown.
To estimate the all-cause mortality risk for patients newly ...prescribed opioids and benzodiazepines concurrently relative to patients prescribed benzodiazepines only, opioids only, or neither medication.
This propensity score-matched, retrospective, cohort study included 17,476 patients receiving Veterans Affairs (VA) health care between October 1, 2009, and September 30, 2011, and diagnosed with posttraumatic stress disorder identified using ICD-9-CM code 309.81. One-year total and cause-specific mortality was assessed by hazard ratios and subhazard ratios, adjusted for propensity score, age, baseline psychiatric and medical comorbidity, and daily medication dose.
Concurrent users (n = 4,369) were propensity score matched 1:1 with benzodiazepine-only users, opioid-only users, and nonusers. One year after medication start, the concurrent cohort had higher rates of all-cause mortality (116 deaths) relative to benzodiazepine-only (75 deaths; adjusted hazard ratio = 1.52; 95% CI, 1.14-2.03), opioid-only (67 deaths; 1.76; 95% CI, 1.32-2.35), and nonuser (60 deaths; 1.85; 95% CI, 1.30-2.64) cohorts. Risk of overdose death was greater among patients in the concurrent cohort relative to patients in the benzodiazepine-only (adjusted subhazard ratio = 2.59; 95% CI, 1.00-6.66), opioid-only (2.58; 95% CI, 1.09-6.11), and nonuser (9.16; 95% CI, 2.27-37.02) cohorts. For circulatory disease-related deaths, the adjusted subhazard ratio for concurrent medication users was 1.81 (95% CI, 1.01-3.24) relative to nonusers.
New coprescription of opioids and benzodiazepines was associated with increased all-cause mortality and overdose death compared with new prescription of benzodiazepines only, opioids only, or neither medication and increased circulatory disease-related death relative to neither medication.
Current medications for alcohol use disorder do not target brain noradrenergic pathways. Theoretical and preclinical evidence suggests that noradrenergic circuits may be involved in alcohol ...reinforcement and relapse. After a positive pilot study, the authors tested the α-1 adrenergic receptor antagonist prazosin to treat alcohol use disorder in a larger sample.
Ninety-two participants with alcohol use disorder but without posttraumatic stress disorder were randomly assigned to receive prazosin or placebo in a 12-week double-blind study. Medication was titrated to a target dosing schedule of 4 mg in the morning, 4 mg in the afternoon, and 8 mg at bedtime by the end of week 2. The behavioral platform was medical management. Participants provided daily data on alcohol consumption. Generalized linear mixed-effects models were used to examine the impact of prazosin compared with placebo on number of drinks per week, number of drinking days per week, and number of heavy drinking days per week.
Eighty participants completed the titration period and were included in the primary analyses. There was a significant interaction between condition and week for both number of drinks and number of heavy drinking days, such that the rate of drinking and the probability of heavy drinking showed a greater decrease over time for participants in the prazosin condition compared with those in the placebo condition. Participants in the prazosin condition were more likely to report drowsiness and edema than participants in the placebo condition.
Prazosin holds promise as a harm-reduction pharmacologic treatment for alcohol use disorder and deserves further evaluation by independent research groups.
ABSTRACT
Opioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist ...treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. Our goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. We provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. We provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidances, a warmline and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1–125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidances were downloaded more than 1000 times. The warmline averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care.
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