IMPORTANCE Obesity is associated with chronic noncancer pain. It is not known if opioid use for chronic pain in obese individuals undergoing bariatric surgery is reduced.OBJECTIVES To determine opioid use following bariatric surgery in patients using opioids chronically for pain control prior to their surgery and to determine the effect of preoperative depression, chronic pain, or postoperative changes in body mass index (BMI) on changes in postoperative chronic opioid use. DESIGN, SETTING, AND PARTICIPANTSRetrospective cohort study in a distributed health network (10 demographically and geographically varied US health care systems) of 11 719 individuals aged 21 years and older, who had undergone bariatric surgery between 2005 and 2009, and were assessed 1 year before and after surgery, with latest follow-up by December 31, 2010.MAIN OUTCOMES AND MEASURES Opioid use, measured as morphine equivalents 1 year before and 1 year after surgery, excluding the first 30 postoperative days. Chronic opioid use is defined as 10 or more opioid dispensings over 90 or more days or as dispensings of at least a 120-day supply of opioids during the year prior to surgery. RESULTS Before surgery, 8% (95% CI, 7%-8%; n = 933) of bariatric patients were chronic opioid users. Of these individuals, 77% (95% CI, 75%-80%; n = 723) continued chronic opioid use in the year following surgery. Mean daily morphine equivalents for the 933 bariatric patients who were chronic opioid users before surgery were 45.0 mg (95% CI, 40.0-50.1) preoperatively and 51.9 mg (95% CI, 46.0-57.8) postoperatively (P < .001). For this group with chronic opiate use prior to surgery, change in morphine equivalents before vs after surgery did not differ between individuals with loss of more than 50% excess BMI vs those with 50% or less (>50% BMI loss: adjusted incidence rate ratio [adjusted IRR, 1.17; 95% CI, 1.07-1.28] vs Յ50% BMI loss [adjusted IRR, 1.03; 95% CI, 0.93-1.14] model interaction, P = .06). In other subgroup analyses of preoperative chronic opioid users, changes in morphine equivalents before vs after surgery did not differ between those with or without preoperative diagnosis of depression or chronic pain (depression only [n = 75; IRR, 1.08; 95% CI, 0.90-1.30]; chronic pain only [n = 440; IRR, 1.17; 95% CI, 1.08-1.27]; both depression and chronic pain [n = 226; IRR, 1.11; 95% CI, 0.96-1.28]; neither depression nor chronic pain [n = 192; IRR, 1.22; 95% CI, 0.98-1.51); and P values for model interactions when compared with neither were P = .42 for depression, P = .76 for pain, and P = .48 for both. CONCLUSIONS AND RELEVANCEIn this cohort of patients who underwent bariatric surgery, 77% of patients who were chronic opioid users before surgery continued chronic opioid use in the year following surgery, and the amount of chronic opioid use was greater postoperatively than preoperatively. These findings suggest the need for better pain management in these patients following surgery.

Two observational data sources offer preliminary support that PMPs are effective. Future efforts should evaluate what PMP characteristics are most effective and which opioids are most impacted.

WHAT'S KNOWN ON THIS SUBJECT: Screening for hypertension in asymptomatic children and adolescents occurs during routine care. For those with elevated blood pressure, a repeat measurement within 1 to 2 weeks is recommended. However, little is known about patterns of care after an incident elevated blood pressure. WHAT THIS STUDY ADDS:In a population of 72 625 children and adolescents, 6108 (8.4%) had an incident elevated blood pressure. Among these, 1275 (20.9%) had their blood pressure measurement repeated within 1 month. However, few individuals with an incident elevated blood pressure subsequently developed hypertension.abstract BACKGROUND AND OBJECTIVE: Screening for hypertension in children occurs during routine care. When blood pressure (BP) is elevated in the hypertensive range, a repeat measurement within 1 to 2 weeks is recommended. The objective was to assess patterns of care after an incident elevated BP, including timing of repeat BP measurement and likelihood of persistently elevated BP. METHODS:This retrospective study was conducted in 3 health care organizations. All children aged 3 through 17 years with an incident elevated BP at an outpatient visit during 2007 through 2010 were identified. Within this group, we assessed the proportion who had a repeat BP measured within 1 month of their incident elevated BP and the proportion who subsequently met the definition of hypertension. Multivariate analyses were used to identify factors associated with follow-up BP within 1 month of initial elevated BP.RESULTS: Among 72 625 children and adolescents in the population, 6108 (8.4%) had an incident elevated BP during the study period. Among 6108 with an incident elevated BP, 20.9% had a repeat BP measured within 1 month. In multivariate analyses, having a followup BP within 1 month was not significantly more likely among individuals with obesity or stage 2 systolic elevation. Among 6108 individuals with an incident elevated BP, 84 (1.4%) had a second and third consecutive elevated BP within 12 months. CONCLUSIONS:Whereas .8% of children and adolescents had an incident elevated BP, the great majority of BPs were not repeated within 1 month. However, relatively few individuals subsequently met the definition of hypertension. Pediatrics 2013;132:e349-e355 AUTHORS:

BACKGROUND: It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. OBJECTIVES:To assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. PATIENTS AND METHODS:Retrospective cohort study of adults aged ≥65 with mild cognitive impairment (MCI) or dementia and ≥ 2 additional chronic conditions (N=10698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the Anticholinergic Cognitive Burden (ACB) scale, falls and fall-related injuries. RESULTS:During a median follow-up of 366 days, 63% of the cohort used ≥1 ACB drug; 2015 (18.8%) people suffered a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when Level 2 and Level 3 drugs were used in combination (HR 2.06, CI 1.51, 2.83). Multiple ACB Level 1 drugs taken

Objectives: Crotalidae polyvalent immune Fab (ovine) (FabAV) is commonly used in the treatment of symptomatic North American crotaline snake envenomation. When approved by the U.S. Food and Drug Administration in 2000, the incidences of immediate hypersensitivity reactions and serum sickness were reported as 0.14 and 0.18, respectively. The objective of this meta-analysis was to evaluate the incidence of immediate hypersensitivity reactions and serum sickness reported in studies of patients treated with FabAV therapy after North American crotaline envenomation. Methods:The authors searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to September 20, 2010, for English-language medical literature and cross-referenced bibliographies of reviewed articles. The published abstracts of the major toxicology conferences were also searched. All prospective and retrospective cohort studies with patients receiving FabAV therapy for North American crotaline envenomations were eligible for data abstraction. Two content experts reviewed full-text articles and extracted relevant study design and outcome data. Proportions of immediate hypersensitivity and serum sickness for each study were analyzed in a random-effects model to produce an overall estimate of immediate hypersensitivity and serum sickness incidence associated with FabAV administration.Results: The literature search revealed 11 unique studies of patients who received FabAV that contained information on immediate hypersensitivity reactions and serum sickness. The meta-analysis produced a combined estimate of the incidence of immediate hypersensitivity of 0.08 (95% confidence interval [CI] = 0.05 to 0.11) and a combined estimate of the incidence of serum sickness of 0.13 (95% CI = 0.07 to 0.21). Conclusions:In this systematic literature review and meta-analysis, the combined estimates of the incidence of immediate hypersensitivity reactions and serum sickness from FabAV in the treatment of symptomatic North American crotaline envenomations appear to be lower than previously reported, at 0.08 and 0.13, respectively. ACADEMIC EMERGENCY MEDICINE 2012; 19:121- (CroFab, FabAV) has become the mainstay of antivenom therapy in the treatment of North American crotaline snakebite and is the only antivenom currently available for use in this population. Forty-four percent of patients whose cases were reported to U.S. poison centers in 2007 were treated with antivenom, an increase from 30% in 2000. 4 While it is unclear why exactly antivenom use has been increasing, this is likely multifactorial. Reasons may include practitioner familiarity and comfort, as well as the presumed safety of FabAV biologics.As with any biologic product, immediate hypersensitivity and serum sickness reactions can occur following antivenom administration. FabAV was first approved for noninvestigational human use based on the results of two human clinical trials.5-7 All prospective clinical trials maintain active surveillance for adverse drug reactions throughout these studies. Taken ...

Background: There are no evidence-based recommendations for statin continuation or discontinuation near the end of life. However, some expert opinion recommends continuing statins prescribed for secondary versus primary prevention of cardiovascular disease. Objectives: Our aim was to explore statin prescribing patterns in a longitudinal cohort of individuals with lifelimiting illness, and to evaluate differences in these patterns based on secondary versus primary prevention of cardiovascular disease. Design and setting: This study was a retrospective cohort analysis of 539 persons in an integrated, not-for-profit health maintenance organization (HMO) setting who were receiving statins at diagnosis of a cancer with 0% to 25% predicted 5-year survival. Of the cohort patients, 343 were taking statins for secondary prevention and 196 for primary prevention of cardiovascular disease. Measurements included number and timing of statin refills between diagnosis and date of death, disenrollment, or the end of the observation period. Results: Four hundred and ninety-six cohort members died within the observation period. Fifty-eight percent of the secondary prevention and 62% of the primary prevention group had at least one statin refill after diagnosis. There were no significant differences between groups for number of days between diagnosis and last refill, or between last refill and death. Two deaths were attributable to cardiovascular causes in each group. Conclusions: Our retrospective cohort analysis of persons with incident poor-prognosis cancer describes diminished, but persistent statin refills after diagnosis. Neither timing of statin discontinuation nor cardiovascular mortality differed by prescribing indication. There may be an opportunity to reevaluate medication burden in persons taking statins for primary prevention, and it is unclear whether continuing statins prescribed for secondary prevention affects cardiovascular outcomes.

Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.

Background Implantable cardioverter defibrillators (ICDs) are increasingly used for primary prevention followingrandomized controlled trials (RCTs) demonstrating that they reduce the risk of death in patients with left ventricular systolic dysfunction (LVSD). The extent to which the clinical characteristics and long-term outcomes of unselected, community-based patients with LVSD undergoing primary prevention ICD implantation in a real-world setting compare with those enrolled in the RCTs is not well characterized. The Longitudinal Study of ICDs is being conducted to address these questions. Methods and Results The study cohort includes consecutive patients undergoing primary prevention ICD placement between 1/1/2006 and 12/31/2009 in seven health plans. Baseline clinical characteristics were acquired from the NCDRICD Registry. Longitudinal data collection is underway and will include hospitalization, mortality, and resource utilization from the Virtual Data Warehouse. Data regarding ICD therapies will be obtained through chart abstraction and adjudicated by a panel of experts in device therapy. Compared with the populations of primary prevention ICD therapy RCTs, the cohort (n=2,621) is on average significantly older (by 2.5-6.5 years); more often female, more often from racial and ethnic minority groups, and has a significantly higher burden of coexisting conditions. The cohort is similar, however, to a national population undergoing primary prevention ICD placement. Conclusions Patients undergoing primary prevention ICD implantation in the Longitudinal Study of ICDs differ from those enrolled in the RCTs that established the efficacy of ICDs. Understanding a broad range of health outcomes, including ICD therapies, in this cohort will provide patients, clinicians, and policy-makers with contemporary data to inform decision-making.