Serious infection is a recognized complication of intravenous drug abuse, and a major cause of morbidity and mortality in this patient population. Trends in rates and the associated cost of serious infections related to opioid abuse/dependence have not been previously investigated in the context of the US opioid use epidemic. Our study, using a nationally representative sample of U.S. inpatient hospitalizations, showed that hospitalizations related to opioid abuse/dependence and hospitalizations related to opioid abuse/dependence with associated serious infection both significantly increased from 2002 to 2012, respectively, from 301,707 to 520,275 and 3,421 to 6,535. Additionally, inpatient charges for both types of hospitalizations have almost quadrupled over the same time period, reaching totals of almost 15 billion for hospitalizations related to opioid abuse/dependence and more than 700 million for those related to associated infection in 2012. Medicaid was the most common primary payer for both types of hospitalizations. Our results characterize the financial burden on the healthcare system related to opioid abuse/dependence and one of the more serious downstream complications of this epidemic. These findings have important implications for the hospitals and government agencies that disproportionately shoulder these costs, and for clinicians, researchers, and policy makers interested in estimating the potential impact of targeted public health interventions on a national level.

ImportanceWith a large proportion of the US adult population vaccinated against SARS-CoV-2, it is important to identify who remains at risk of severe infection despite vaccination.ObjectiveTo characterize risk factors for severe COVID-19 disease in a vaccinated population.Design, Setting, and ParticipantsThis nationwide, retrospective cohort study included US veterans who received a SARS-CoV-2 vaccination series and later developed laboratory-confirmed SARS-CoV-2 infection and were treated at US Department of Veterans Affairs (VA) hospitals. Data were collected from December 15, 2020, through February 28, 2022.ExposuresDemographic characteristics, comorbidities, immunocompromised status, and vaccination-related variables.Main Outcomes and MeasuresDevelopment of severe vs nonsevere SARS-CoV-2 infection. Severe disease was defined as hospitalization within 14 days of a positive SARS-CoV-2 diagnostic test and either blood oxygen level of less than 94%, receipt of supplemental oxygen or dexamethasone, mechanical ventilation, or death within 28 days. Association between severe disease and exposures was estimated using logistic regression models.ResultsAmong 110 760 patients with infections following vaccination (97 614 [88.1%] men, mean [SD] age at vaccination, 60.8 [15.3] years; 26 953 [24.3%] Black, 11 259 [10.2%] Hispanic, and 71 665 [64.7%] White), 10 612 (9.6%) had severe COVID-19. The strongest association with risk of severe disease after vaccination was age, which increased among patients aged 50 years or older with an adjusted odds ratio (aOR) of 1.42 (CI, 1.40-1.44) per 5-year increase in age, such that patients aged 80 years or older had an aOR of 16.58 (CI, 13.49-20.37) relative to patients aged 45 to 50 years. Immunocompromising conditions, including receipt of different classes of immunosuppressive medications (eg, leukocyte inhibitor: aOR, 2.80; 95% CI, 2.39-3.28) or cytotoxic chemotherapy (aOR, 2.71; CI, 2.27-3.24) prior to breakthrough infection, or leukemias or lymphomas (aOR, 1.87; CI, 1.61-2.17) and chronic conditions associated with end-organ disease, such as heart failure (aOR, 1.74; CI, 1.61-1.88), dementia (aOR, 2.01; CI, 1.83-2.20), and chronic kidney disease (aOR, 1.59; CI, 1.49-1.69), were also associated with increased risk. Receipt of an additional (ie, booster) dose of vaccine was associated with reduced odds of severe disease (aOR, 0.50; CI, 0.44-0.57).Conclusions and RelevanceIn this nationwide, retrospective cohort of predominantly male US Veterans, we identified risk factors associated with severe disease despite vaccination. Findings could be used to inform outreach efforts for booster vaccinations and to inform clinical decision-making about patients most likely to benefit from preexposure prophylaxis and antiviral therapy.

The United States is experiencing an epidemic of nonmedical opioid use and opioid overdose-related deaths. As a result, there have been a number of public health interventions aimed at addressing this epidemic. However, these interventions fail to address care of individuals with opioid use disorder during hospitalizations and, therefore, miss a key opportunity for intervention. The role of hospitalists in managing hospitalized patients with opioid use disorder is not established. In this review, we discuss the inpatient management of individuals with opioid use disorder, including the treatment of withdrawal, benefits of medication-assisted treatment, and application of harm-reduction strategies.

Background Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. Methods and findings We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were

Strain D7 of Saccharomyces cerevisiae was used to measure the induction by bleomycin (BLM) of mitotic recombination at the trp5 locus and point mutations at ilv1 in the presence and absence of acridine compounds. BLM is a potent mutagen and recombinagen in the D7 assay. The acridines vary, some being mutagenic or recombinagenic and others not. Combined treatments were used to distinguish whether a genetically inactive acridine has no effect on the genetic activity of BLM or modulates its action. When an acridine is itself genetically active, combined treatments were used to determine whether its effects are additive with those of BLM or whether there is interaction between the two compounds. Acridine compounds that share the ability to intercalate between the base pairs of DNA but differ in their mutagenic specificity owing to the presence of different substituent groups were analysed. Clear potentiation and synergistic interactions were detected in combined treatments with BLM and aminoacridines, nitroacridines or an acridine mustard. Potentiation and synergy were also observed in sequential exposures in which the yeast were grown in the presence of acridine compounds and then treated with BLM in the absence of free acridine. The results are consistent with an increase in BLM susceptibility conferred by acridine intercalation. It is likely that the intercalating agents increase the access of BLM to the minor groove of DNA, where it abstracts a hydrogen from the 4' position of deoxyribose, creating a free radical that is processed into strand breaks.

Background: Pain is common among hospitalized patients. Inpatient opioid prescribing is not without risk. Acute pain management guidelines could inform safe opioid prescribing in the hospital and limit associated unintended consequences. Purpose: To evaluate the quality and content of existing guidelines for acute, non-cancer pain management. Data Sources: The National Guideline Clearinghouse, MEDLINE via PubMed, websites of relevant specialty societies and other organizations, and selected international search engines. Study Selection: Guidelines published between January 2010 to August 2017 addressing acute, non-cancer pain management among adults were considered. Guidelines focused on chronic pain, specific diseases, and non-hospital setting were excluded. Data Extraction: Quality assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Data Synthesis: Four guidelines met selection criteria. Most recommendations were based on expert consensus. Guidelines recommended restricting opioids to severe pain or pain that has not responded to non-opioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with non-opioid analgesics. Guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding risks and side effects of opioid therapy. Additional recommendations included using an opioid dose conversion guide, avoidance of co-administration of parenteral and oral opioids, and using caution when co-prescribing opioids with other central nervous system depressants. Conclusions: Guidelines, based largely on expert opinion, recommend judicious opioid prescribing for severe, acute pain. Future work should assess the implications of these recommendations on hospital-based pain management.

Background: Hospitalizations related to the consequences of opioid use are rising.National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.Objective: Evaluate the quality and content of existing guidelines for OUD treatment and management.

Introduction: We created a standardized workshop to engage residents in quality improvement (QI) using the root cause analysis model. The workshop allows for a robust learning experience while providing solutions derived from clinicians to address important local problems. No prerequisite knowledge or experience is required. Methods: The workshop is facilitated by one or more moderators, ideally with experience in QI. An interdisciplinary group of residents, medical students, nurses, and other attendees comprise an audience which actively engages in workshop activities. Facilitators follow a scripted model to teach important patient safety concepts with frequent break-outs for hands-on application of QI tools. During the workshop, participants create a process map and fishbone diagram, as well as develop and critically evaluate novel interventions. Results: Over the course of one academic year, the workshop has been implemented 17 times with roughly 25 internal medicine residents in attendance at each workshop. In addition, the workshop was run online for 126 participants with varied exposure to QI techniques. Forty percent of these participants completed a survey indicating that over 89% learned something new, 87% felt they could apply the material to their work, and 95% would recommend the workshop to a colleague. Discussion: This 60-minute workshop can provide hands-on QI experience in a standardized format to achieve the dual objectives of teaching QI to clinicians and allowing them to generate innovations. The module can be used for internal case development and trainee participation, but prepared cases are provided for facilitators without the resources for local case development.