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Park J, Engstrom G, Ouslander JG. Prescribing Benzodiazepines and Opioids and Clinical Characteristics Associated With 30-Day Hospital Return in Patients Aged ≥75 Years: Secondary Data Analysis. J Gerontol Nurs 2024; 50:25-33. [PMID: 38569101 DOI: 10.3928/00989134-20240312-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE The current study compared prevalence of opioid or benzodiazepine (BZD) prescription and co-prescription of opioids and BZD at discharge and return to a community hospital within 30 days, as well as identified clinical characteristics associated with hospital return in patients aged ≥75 years. METHOD A secondary analysis of a database created during implementation of the Safe Transitions for At Risk Patients program at a 400-bed community teaching hospital in south Florida was conducted. Multivariable logistic regression analyses were performed to identify significant demographic and clinical characteristics associated with return to the hospital within 30 days of discharge. RESULTS A total of 24,262 participants (52.6% women) with a mean age of 85.3 (SD = 6.42) years were included. More than 20% in each central nervous system prescription group (i.e., opioids only, BZD only, opioids and BZD) returned to the hospital within 30 days of discharge. Demographic and chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes) and poly-pharmacy were significant factors of a 30-day return to the hospital. CONCLUSION Findings highlight the importance of hospital nurses' role in identifying high-risk patients, educating patients and caregivers, monitoring them closely, communicating with primary care physicians and specialists, and conducting intensive follow up via telephone to avoid 30-day rehospitalization. [Journal of Gerontological Nursing, 50(4), 25-33.].
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Lyons PG, Hough CL. Antimicrobials in Sepsis: Time to Pay Attention to When Delays Happen. Ann Am Thorac Soc 2023; 20:1239-1241. [PMID: 37655955 PMCID: PMC10502879 DOI: 10.1513/annalsats.202306-519ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Patrick G Lyons
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Department of Medical Informatics and Clinical Epidemiology, and
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Catherine L Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
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Keller MS, Carrascoza-Bolanos J, Breda K, Kim LY, Kennelty KA, Leang DW, Murry LT, Nuckols TK, Schnipper JL, Pevnick JM. Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study. BMJ Open 2023; 13:e066234. [PMID: 36813499 PMCID: PMC9950911 DOI: 10.1136/bmjopen-2022-066234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers. DESIGN We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group. SETTING Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California. PARTICIPANTS Interview participants included physicians, pharmacists, pharmacist technicians, and nurses. RESULTS We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge. CONCLUSIONS While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.
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Affiliation(s)
- Michelle S Keller
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Health Policy and Management, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Kathleen Breda
- Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Linda Y Kim
- Nursing, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Korey A Kennelty
- College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
| | - Donna W Leang
- Pharmacy, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Logan T Murry
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, Iowa, USA
| | - Teryl K Nuckols
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joshua M Pevnick
- Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Champreeda V, Hu R, Chan B, Tomasek O, Lin YH, Weinberg L, Howard W, Tan CO. Nocturnal respiratory abnormalities among ward-level postoperative patients as detected by the Capnostream 20p monitor: A blinded observational study. PLoS One 2023; 18:e0280436. [PMID: 36662703 PMCID: PMC9858304 DOI: 10.1371/journal.pone.0280436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/01/2023] [Indexed: 01/21/2023] Open
Abstract
PURPOSE This prospective observational study aimed to establish the frequency of postoperative nocturnal respiratory abnormalities among patients undergoing major surgery who received ward-level care. These abnormalities may have implications for postoperative pulmonary complications (PPCs). METHODS Eligible patients underwent blinded noninvasive continuous capnography with pulse oximetry using the Capnostream™ 20p monitor over the first postoperative night. All patients received oxygen supplementation and patient-controlled opioid analgesia. The primary outcome was the number of prolonged apnea events (PAEs), defined as end-tidal carbon dioxide (EtCO2) ≤5 mmHg for 30-120 seconds or EtCO2 ≤5 mmHg for >120 seconds with oxygen saturation (SpO2) <85%. Secondary outcomes were the proportion of recorded time that physiological indices were aberrant, including the apnea index (AI), oxygen desaturation index (ODI), integrated pulmonary index (IPI), and SpO2. Exploratory analysis was conducted to assess the associations between PAEs, PPCs, and pre-defined factors. RESULTS Among 125 patients who had sufficient data for analysis, a total of 1800 PAEs occurred in 67 (53.4%) patients. The highest quartile accounted for 89.1% of all events. Amongst patients who experienced any PAEs, the median (IQR) number of PAE/patient was four (2-12). As proportions of recorded time (median (IQR)), AI, ODI, and IPI were aberrant for 12.4% (0-43.2%), 19.1% (2.0-57.1%), and 11.5% (3.1-33.3%) respectively. Only age, ARISCAT, and opioid consumption/kg were associated with PPCs. CONCLUSIONS PAE and aberrant indices were frequently detected on the first postoperative night. However, they did not correlate with PPCs. Future research should investigate the significance of detected aberrations.
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Affiliation(s)
- Vichaya Champreeda
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Brandon Chan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Owen Tomasek
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Yuan-Hong Lin
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Will Howard
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong O. Tan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
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Gabapentin to treat acute alcohol withdrawal in hospitalized patients: A systematic review and meta-analysis. Drug Alcohol Depend 2022; 241:109671. [PMID: 36402053 DOI: 10.1016/j.drugalcdep.2022.109671] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gabapentin is an antiepileptic medication with evidence of benefit in alcohol use disorder patients. The mechanism of action of gabapentin may also benefit patients suffering from acute alcohol withdrawal syndrome (AWS). METHODS A systematic review and meta-analysis were conducted to examine if gabapentin can effectively replace/reduce the use of benzodiazepines for the treatment of acute alcohol withdrawal symptoms in hospitalized patients. Time to alcohol withdrawal symptom resolution, amount of benzodiazepines administered, rate of resolution of alcohol withdrawal symptoms, serious withdrawal-related complications, and hospital length of stay (LOS) were examined. RESULTS Eight retrospective studies (n = 2030) were included in this meta-analysis. There were no studies that examined study outcomes for patients who received only gabapentin and no benzodiazepines; in all studies, gabapentin-treated patients may have received benzodiazepines prior to gabapentin. There were no significant differences between gabapentin-treated and benzodiazepine-treated groups in time to symptom resolution, amount benzodiazepines administered, withdrawal-related complications, or LOS. There was a significant difference in the rate of symptom resolution favoring gabapentin-treated patients (p = 0.05); however, this analysis included only one study. Subgroup analyses of severe AWS patients revealed a significant decrease in LOS (p = 0.04) and a decrease in amount of benzodiazepines administered (p = 0.02) in gabapentin-treated patients, but these analyses included only one study. Subgroup analysis of patients receiving only gabapentin without benzodiazepines found a significantly decreased LOS in the gabapentin group compared to the benzodiazepine group (p < 0.001), but this analysis included only two studies. CONCLUSIONS There is insufficient evidence to support the widespread use of gabapentin to treat inpatients suffering AWS. All studies included in this meta-analysis are retrospective with high risk of confounding. Well-designed, randomized, controlled studies of gabapentin to treat patients with AWS are required.
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Lauffenburger JC, Coll M, Kim E, Robertson T, Oran R, Haff N, Hanken K, Avorn J, Choudhry NK. Prescribing decision making by medical residents on night shifts: A qualitative study. MEDICAL EDUCATION 2022; 56:1032-1041. [PMID: 35611564 PMCID: PMC9474569 DOI: 10.1111/medu.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Prescribing of medications with well-known adverse effects, like antipsychotics or benzodiazepines, during hospitalisation is extremely common despite guideline recommendations against their use. Barriers to optimal prescribing, including perceived pressure from allied health professionals and fatigue, may be particularly pronounced for less experienced medical residents, especially during night shifts when these medications are often prescribed. Under these circumstances, physicians may be more likely to use 'quick', often referred to as System 1 choices, rather than 'considered' System 2 strategies for decisions. Understanding how medical residents use, these different cognitive approaches could help develop interventions to improve prescribing. METHODS To understand decision-making and contextual contributors that influence suboptimal prescribing during night coverage by medical residents, we conducted semi-structured qualitative interviews with residents in general medicine inpatient settings. The interviews elicited perspectives on shift routines, stressful situations, factors influencing prescribing decision making and hypothetical measures that could improve prescribing. Interviews were audio-recorded and transcribed. Data were analysed using codes developed by the team to generate themes using immersion/crystallisation approaches. RESULTS We conducted interviews with 21 medical residents; 47% were female, 43% were White, and 43% were Asian. We identified five key themes: (i) time pressures affecting prescribing decisions, (ii) fears of judgement by senior physicians and peers and being responsible for patient outcomes, (iii) perceived pressure from nursing staff, amplified by nurses' greater experience, (iv) clinical acuity as a key factor influencing prescribing, and (v) strategies to improve communication between members of the care team, like ensuring adequate hand-off by day teams. CONCLUSION Medical residents highlighted numerous contextual factors that promote quick thinking rather than slower thinking when prescribing on night shifts, particularly time constraints, perceived pressure and patient clinical acuity. Interventions aimed at reducing prescribing should address how to manage stress and perceived pressure in decision making.
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Affiliation(s)
- Julie C. Lauffenburger
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Maxwell Coll
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Erin Kim
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Nancy Haff
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Kaitlin Hanken
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jerry Avorn
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Soong C, Ethier C, Lee Y, Othman D, Burry L, Wu PE, Ng KA, Matelski J, Liu B. Reducing Sedative-Hypnotics Among Hospitalized Patients: a Multi-centered Study. J Gen Intern Med 2022; 37:2345-2350. [PMID: 34981347 PMCID: PMC9360352 DOI: 10.1007/s11606-021-07292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 11/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. OBJECTIVE, DESIGN, AND PARTICIPANTS We aimed to examine whether a sedative-hypnotic reduction quality improvement bundle decreases the rate of sedative-hypnotic use among hospitalized patients, who were previously naïve to sedative-hypnotics. This interrupted time series study occurred between May 2016 and January 2019. Control data for 1 year prior to implementation and intervention data for at least 16 months were collected. The study occurred on 7 inpatient wards (general medicine, cardiology, nephrology, general surgery, and cardiovascular surgery wards) across 5 teaching hospitals in Toronto, Canada. INTERVENTION Participating wards implemented a sedative-hypnotic reduction bundle (i.e., order set changes, audit-feedback, pharmacist-enabled medication reviews, sleep hygiene, daily sleep huddles, and staff/patient/family education) aimed to reduce in-hospital sedative-hypnotic initiation for insomnia in patients who were previously naïve to sedative-hypnotics. Each inpatient ward adapted the bundle prior to sustaining the intervention for a minimum of 16 months. MAIN MEASURES The primary outcome measure was the proportion of sedative-hypnotic-naïve inpatients newly prescribed a sedative-hypnotic for sleep in hospital. Secondary measures include prescribing rates of other sedating medications, fall rates, length of stay, and mortality. KEY RESULTS We included 8,970 patient discharges in the control period and 10,120 in the intervention period. Adjusted sedative-hypnotic prescriptions among naïve patients decreased from 15.48% (95% CI: 6.09-19.42) to 9.08% (p<0.001) (adjusted OR 0.814; 95% CI: 0.667-0.993, p=0.042). Unchanged secondary outcomes included mortality (adjusted OR 1.089; 95% CI: 0.786-1.508, p=0.608), falls (adjusted rate ratio 0.819; 95% CI: 0.625-1.073, p=0.148), or other sedating drug prescriptions (adjusted OR 1.046; 95% CI: 0.873-1.252, p=0.627). CONCLUSIONS A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.
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Affiliation(s)
- Christine Soong
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, 433-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Centre for Quality and Patient Safety, University of Toronto, Toronto, ON, Canada.
| | - Cheryl Ethier
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada
| | - Yuna Lee
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Dalia Othman
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada
| | - Lisa Burry
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada.,Department of Pharmacy, Sinai Health System, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Peter E Wu
- Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Karen A Ng
- Division of Geriatric Medicine, Sinai Health System, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Benzodiazepine Treatment and Hospital Course of Medical Inpatients With Alcohol Withdrawal Syndrome in the Veterans Health Administration. Mayo Clin Proc Innov Qual Outcomes 2022; 6:126-136. [PMID: 35224452 PMCID: PMC8855212 DOI: 10.1016/j.mayocpiqo.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kukielka E. The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities. PATIENT SAFETY 2021. [DOI: 10.33940/data/2021.12.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Benzodiazepines may increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in patients 65 years and older. The concomitant use of benzodiazepines and opioids may also be inappropriate for older adults due to the increased risk of overdose. We searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of patient safety events related to the concomitant use of benzodiazepines and opioids in older adults in order to gain a better understanding of the potential risks of using these medications in combination. We identified 80 reports in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication. Reports were reviewed to determine the ADR(s) experienced by the patient. Changes in mental status were most common, occurring in more than two-thirds of reports (68.8%; 55 of 80), followed by respiratory reactions (51.3%; 41 of 80) and cardiovascular reactions (25.0%; 20 of 80). In over two-thirds of reports (70.0%; 56 of 80), the patient received a reversal agent, either flumazenil (10.7%; 6 of 56) or naloxone (35.7%; 20 of 56), or both (53.6%; 30 of 56). The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.
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Urman RD, Khanna AK, Bergese SD, Buhre W, Wittmann M, Le Guen M, Overdyk FJ, Di Piazza F, Saager L. Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial. J Clin Anesth 2021; 70:110167. [PMID: 33493688 DOI: 10.1016/j.jclinane.2021.110167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Opioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression. DESIGN Prospective observational trial. SETTING 16 general care medical and surgical wards in Asia, Europe, and the United States. PATIENTS 1335 patients receiving parenteral opioids. INTERVENTIONS Blinded, alarm-silenced continuous capnography and pulse oximetry monitoring. MEASUREMENTS Opioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO2 ≤ 85%, or ETCO2 ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event. RESULTS Across all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5-76.7) MME, 31.0 (6.2-99.0) MME, and 7.2 (1.7-18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424-0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322-0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression. CONCLUSIONS Despite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. REGISTRATION NUMBER: www.clinicaltrials.gov, ID: NCT02811302.
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Affiliation(s)
- Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, and Neurological Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Wolfgang Buhre
- Department of Anesthesiology, University Medical Center, Maastricht, Netherlands
| | - Maria Wittmann
- Department of Anaesthesiology, University Hospital Bonn, Bonn, Germany
| | - Morgan Le Guen
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | | | - Fabio Di Piazza
- Medtronic Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | - Leif Saager
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University Medical Center Goettingen, Germany; Outcomes Research Consortium, Cleveland, OH, USA
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Attin M, Abiola S, Magu R, Rosero S, Apostolakos M, Groth CM, Block R, Lin CDJ, Intrator O, Hurley D, Arcoleo K. Polypharmacy prior to in-hospital cardiac arrest among patients with cardiopulmonary diseases: A pilot study. Resusc Plus 2020; 4. [PMID: 33969325 PMCID: PMC8104360 DOI: 10.1016/j.resplu.2020.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Background Patterns of medication administration prior to in-hospital cardiac arrest (I-HCA) and the potential impact of these on patient outcomes is not well-established. Accordingly, types of medications administered in the 72 h prior to I-HCA were examined in relation to initial rhythms of I-HCA and survival. Methods A retrospective, pilot study was conducted among 96 patients who experienced I-HCA. Clinical characteristics and treatments including medications were extracted from electronic health records. Relative risk (RR) of medications or class of medications associated with the initial rhythms of I-HCA and return of spontaneous circulation (ROSC) were calculated. Results Two distinct sub-groups were identified that did not survive to hospital discharge (n = 31): 1) those who received either vasopressin/desmopressin (n = 16) and 2) those who received combinations of psychotherapeutic agents with anxiolytics, sedatives, and hypnotics (n = 15) prior to I-HCA. The risk of pulseless electrical activity and asystolic arrest was high in patients who received sympathomimetic agents alone or in combination with β-Adrenergic blocking agents, (RR = 1.40, 1.41, respectively). Vasopressin and a combination of vasopressin and fentanyl were associated with risk of unsuccessful ROSC (RR = 2.50, 2.38, respectively). Conclusions The types of medications administered during inpatient care may serve as a surrogate marker for identifying patients at risk of specific initial rhythms of I-HCA and survival.
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Affiliation(s)
- Mina Attin
- School of Nursing, University of Rochester, NY, USA
| | - Simeon Abiola
- Clinical and Translational Science Institute, School of Medicine and Dentistry, University of Rochester, NY, USA
| | - Rijul Magu
- School of Nursing, University of Rochester, NY, USA
| | - Spencer Rosero
- Division of Cardiology, Cardiac Electrophysiology, Department of Medicine, University of Rochester, NY, USA
| | - Michael Apostolakos
- Division of Pulmonary Diseases, Critical Care, Department of Medicine, University of Rochester, NY, USA
| | - Christine M Groth
- Division of Pharmacy, Department of Medicine, University of Rochester, NY, USA
| | - Robert Block
- Division of Cardiology, Department of Medicine, University of Rochester, NY, USA
| | - C D Joey Lin
- Department of Mathematics and Statistics, San Diego State University, San Diego, USA
| | - Orna Intrator
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, New York, Geriatrics & Extended Care Data & Analysis Center (GEC DAC), Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, USA
| | - Deborah Hurley
- Department of Learning and Development in the University of Rochester Medical Center, Rochester, NY, USA
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Abstract
BACKGROUND Insomnia is a common sleep disorder with symptoms including difficulty falling asleep and early awakening. Guipi decoction is widely used in clinical treatment of insomnia in China. However, there is a lack of systematic evaluation and analysis of Guipi decoction. Therefore, our study will provide efficacy assessments and adverse events assessments. METHODS A comprehensive search for randomized controlled trials of Gupi decoction treatments for insomnia will be carried in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trial (CENTRAL), CINAHL, AMED and Chinese databases include CBM, CNKI, CQVIP, and Wanfang from their inceptions to May 2020. Relevant reference lists, Baidu Scholar and grey literature will also be checked. Two experienced reviewers will independently search all databases. Primary outcomes include Pittsburgh sleep quality index and clinical effective rate, and secondary outcomes include traditional Chinese medicine syndrome, adverse events, and Epworth Sleepiness Scale. Review Manager 5.3 software will be used analyze all data. RESULTS This article will be dedicated to assessing the efficacy and safety of Guipi decoction for insomnia. CONCLUSION The conclusion of this systematic review will provide evidence to judge whether Guipi Decoction is an effective therapeutic intervention for patient with insomnia. Maybe these results could potentially be helpful for improving the therapeutic strategy of patients with insomnia. PROSPERO REGISTRATION NUMBER CRD 42020164911.
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Affiliation(s)
- Mao Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Rui Lan
- The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Yong Wen
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Kejin Shi
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
| | - Dongdong Yang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu
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13
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Chen J, Wu G, Michelson A, Vesoulis Z, Bogner J, Corrigan JD, Payne PRO, Li F. Mining reported adverse events induced by potential opioid-drug interactions. JAMIA Open 2020; 3:104-112. [PMID: 32607492 PMCID: PMC7309259 DOI: 10.1093/jamiaopen/ooz073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/17/2019] [Accepted: 03/02/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Opioid-based analgesia is routinely used in clinical practice for the management of pain and alleviation of suffering at the end of life. It is well-known that opioid-based medications can be highly addictive, promoting not only abuse but also life-threatening overdoses. The scope of opioid-related adverse events (AEs) beyond these well-known effects remains poorly described. This exploratory analysis investigates potential AEs from drug-drug interactions between opioid and nonopioid medications (ODIs). MATERIALS AND METHODS In this study, we conduct an initial exploration of the association between ODIs and severe AEs using millions of AE reports available in FDA Adverse Event Reporting System (FAERS). The odds ratio (OR)-based analysis and visualization are proposed for single drugs and pairwise ODIs to identify associations between AEs and ODIs of interest. Moreover, the multilabel (multi-AE) learning models are employed to evaluate the feasibility of AE prediction of polypharmacy. RESULTS The top 12 most prescribed opioids in the FAERS are identified. The OR-based analysis identifies a diverse set of AEs associated with individual opioids. Moreover, the results indicate many ODIs can increase the risk of severe AEs dramatically. The area under the curve values of multilabel learning models of ODIs for oxycodone varied between 0.81 and 0.88 for 5 severe AEs. CONCLUSIONS The proposed data analysis and visualization are useful for mining FAERS data to identify novel polypharmacy associated AEs, as shown for ODIs. This approach was successful in recapitulating known drug interactions and also identified new opioid-specific AEs that could impact prescribing practices.
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Affiliation(s)
- Jinzhao Chen
- Department of Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Gaoyu Wu
- Institute for Informatics (I2), Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Andrew Michelson
- Institute for Informatics (I2), Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Zachary Vesoulis
- Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio, USA
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio, USA
| | - Philip R O Payne
- Institute for Informatics (I2), Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Fuhai Li
- Institute for Informatics (I2), Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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14
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Herzig SJ, Stefan MS, Pekow PS, Shieh MS, Soares W, Raghunathan K, Lindenauer PK. Risk Factors for Severe Opioid-Related Adverse Events in a National Cohort of Medical Hospitalizations. J Gen Intern Med 2020; 35:538-545. [PMID: 31728892 PMCID: PMC7018928 DOI: 10.1007/s11606-019-05490-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/12/2019] [Accepted: 09/25/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opioids are a leading cause of adverse drug events in the hospital. Guidelines recommend that physicians assess the risks of opioids and discuss them with patients when considering opioid use. There are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ORADEs) in hospitalized medical patients. OBJECTIVE To identify independent risk factors for severe ORADEs in hospitalized medical patients. DESIGN Retrospective cohort study. PATIENTS Medical patients hospitalized at US, non-federal, and acute care facilities, with at least one pharmacy charge for an opioid during hospitalization. We excluded patients with metastatic malignancy, hospice, or palliative care billing codes. MAIN MEASURES We used Cox proportional hazards modeling to identify risk factors for severe ORADEs, defined by a pharmacy charge for naloxone. Candidate risk factors were chosen a priori, based on clinical grounds and prior literature. KEY RESULTS Among 731,208 hospitalizations (median age 60, 56.5% female), a severe ORADE occurred in 2727 (0.4%). Independent risk factors included patient characteristics (advanced age, female gender), comorbidities (congestive heart failure, opioid abuse/dependence, non-opioid drug abuse/dependence, psychosis, depression, obstructive sleep apnea), organ failures on admission (respiratory failure, shock/hypotension, renal failure, hepatic failure, acidosis, and neurologic failure), medication co-administrations (antipsychotics and short-acting benzodiazepines), and characteristics of the opioid prescriptions themselves (total dose for the day, parenteral route of administration, and receipt of multiple types of opioids in a day). Although a risk prediction model derived from these factors performed well on stratified k-fold cross-validation (average c-statistics 0.68-0.71), the low incidence of the outcome limited the positive predictive value of the risk score. CONCLUSIONS In this national cohort of medical patients, we identified several risk factors for ORADEs that can be used to inform physician decision-making, conversations with patients about risk, and development and targeting of harm reduction strategies for at-risk populations.
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Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
- School of Public Health and Health Sciences, University of Massachusetts-Amherst, Amherst, MA, USA
| | - Meng-Shiou Shieh
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - William Soares
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Karthik Raghunathan
- Anesthesiology Service, Durham VA Medical Center, Duke University Medical Center, Durham, NC, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
- Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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15
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions. Pain Manag Nurs 2020; 21:7-25. [DOI: 10.1016/j.pmn.2019.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/25/2019] [Accepted: 06/14/2019] [Indexed: 01/12/2023]
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16
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Soong C, Burry L, Cho HJ, Gathecha E, Kisuule F, Tannenbaum C, Vijenthira A, Morgenthaler T. An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients. JAMA Intern Med 2019; 179:965-972. [PMID: 31157831 DOI: 10.1001/jamainternmed.2019.1196] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sedative-hypnotic medications are frequently prescribed for hospitalized patients with insomnia, but they can result in preventable harm such as delirium, falls, hip fractures, and increased morbidity. Furthermore, sedative-hypnotic initiation while in the hospital carries a risk of chronic use after discharge. Disrupted sleep is a major contributor to sedative-hypnotic use among patients in the hospital and other institutional settings. Numerous multicomponent studies on improving sleep quality in these settings have been described, some demonstrating an associated reduction of sedative-hypnotic prescriptions. This selected review summarizes effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation and proposes an implementation strategy to guide quality improvement teams.
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Affiliation(s)
- Christine Soong
- Division of General Internal Medicine, Sinai Health System, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada.,Centre for Quality and Patient Safety, University of Toronto, Ontario, Canada
| | - Lisa Burry
- Division of General Internal Medicine, Sinai Health System, Toronto, Ontario, Canada.,Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Hyung J Cho
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Lown Institute, Brookline, Massachusetts
| | - Evelyn Gathecha
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Flora Kisuule
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
| | - Abi Vijenthira
- Postgraduate Medical Education, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Morgenthaler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
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17
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Baumann SL, Jacobowitz W, Tanzi D, Lewis TA, Krepp MJ, Levy E. A Study of the Use of Psychopharmacologic Agents by Acutely Medically Ill Older Adults. Issues Ment Health Nurs 2018; 39:439-444. [PMID: 29370545 DOI: 10.1080/01612840.2017.1395498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This retrospective study sought to investigate issues related to the safety of psychopharmacological agents used by acutely medically ill hospitalized older adults. It explored if there were any associations between commonly prescribed psychiatric medications that medically ill hospitalized older adults received and adverse events. It also sought to compare the safety of antidepressants, sedative/hypnotics, and antipsychotics, when used as a standing (on a preset schedule) and as needed pro re nata (PRN) basis. The study found that psychopharmacological agents are frequently prescribed for medically ill hospitalized older adults. No statistically significant difference was found as far as safety was concerned. The number of PRN medications that were used, and the total number of medications was associated with increased risk of transfer within the hospital to a higher level of care or transfer upon discharge to long-term-care/rehabilitation or hospice. Overall, the use of psychopharmacological agents did not appear to be related to serious adverse events.
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Affiliation(s)
- Steven L Baumann
- a Nursing, Hunter College, City University of New York, Hunter College , New York City , New York , USA
| | - William Jacobowitz
- b Nursing and Public Health, College of Nursing and Public Health , Adelphi University , Garden City , New York , USA
| | - Donna Tanzi
- c Nursing Education, Nursing Education & Innovation , Huntington Hospital, Northwell Health System , Huntington , New York , USA
| | - Tricia A Lewis
- d Nursing Education , Southside Hospital, Northwell Health System , Bay Shore , New York , USA
| | - Margaret J Krepp
- e Employee Health , Huntington Hospital, Northwell Health System , Huntington , New York , USA
| | - Eileen Levy
- f Psychiatry , Huntington Hospital , Huntington , New York , USA
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18
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Abstract
The use of pro re nata (PRN) medications are a routine part of the treatment provided to most hospitalized older adults. The purpose of this article is to review the risks and benefits of using PRN medications in the acutely medically ill hospitalized older adult. After the discussion of a case study, recommendations are provided nurses and prescribers to reduce the risk of short and long term adverse consequences for the senior in the acute care hospital setting.
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Affiliation(s)
- Steven L Baumann
- Hunter College of the City University of New York, 425, East 25th Street, NYC, NY 10010, USA.
| | - Nina Greif
- Psychiatry Department, Huntington Hospital, 270 Park Ave, Huntington, NY 11743, USA.
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