Notes

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rmance and quality of care. The software represents a significant advance for health services research and is transforming the organization, delivery, and evaluation of primary health care services.
Perioperative pain management guidelines recommend using multimodal analgesia to improve pain control while reducing opioids administered. The primary objective of this study was to assess whether implementing multimodal analgesia on general surgery postoperative pain management order sets would reduce opioid quantities postoperatively.

Opioid-naive patients undergoing nonemergent general surgery procedures were evaluated before and after order set revision. The primary outcome was the total quantity of inpatient opioids administered. PF-573228 The secondary outcomes were inpatient naloxone administration, patient-reported pain scores, and opioid quantities prescribed at discharge.

The average daily opioid consumption was less each postoperative day (POD) after implementing the revised postsurgical multimodal analgesia pain management order set. On POD 1 and POD 2, average opioid consumption was 53.6 and 47.9 oral morphine equivalents (OME) before the multimodal analgesia order set, respectively, compared with 21.2 and 21.4 OME after, respectively (p < 0.01 and p < 0.01, respectively). Average daily opioid consumption through POD 3 was 60.6 OME before and 21.14 OME after the revision. Average daily pain scores were similar on POD 0, 1, and 2 before and after (3.2, 2.8, and 2.4 compared with 2.8, 3.1, and 2.7, respectively; p = 0.09, 0.33, and 0.12, respectively). On POD 3, pain scores were higher in the postorder set group (2.8 compared with 1.9; p < 0.01), but this was considered clinically insignificant. Average daily pain score through POD 3 was 2.6 before implementation compared with 2.8 after implementation. Neither group required naloxone administration.

Using perioperative multimodal analgesia reduces opioid consumption without increasing pain scores.
Using perioperative multimodal analgesia reduces opioid consumption without increasing pain scores.
In recent years, the US has become extensively polarized across social, political, and religious divides. As the cultural, political, and social divides continue to grow, the medical establishment has shown similar divisions between clinicians and patients. However, an inclusive dialogue that recognizes the intellectual and interpersonal boundaries of opposing groups and traditions would provide an avenue toward mutual understanding and further collaboration toward a common goal and solution. One such method for building bridges between opposing groups can be found in interfaith dialogue. The goal of interfaith dialogue is not merely to exchange pleasantries but also to develop a mutual collaboration addressing moral and ethical issues with a unified voice. This is achieved through moving beyond separation and suspicion, inquiring more deeply, sharing both the easy and the difficult parts, moving beyond safe territory, and exploring spiritual practices from other traditions. A physician who exemplified manyh a unified voice. This is achieved through moving beyond separation and suspicion, inquiring more deeply, sharing both the easy and the difficult parts, moving beyond safe territory, and exploring spiritual practices from other traditions. A physician who exemplified many aspects interfaith dialogue in his clinical practice was the late Sir William Osler. Through examining Osler's application of interfaith dialogue, we may develop a framework by which clinicians can actively build new bridges and dialogue between their patients and society.
The programmed death 1 (PD-1) inhibitors may improve survival outcomes of non-small cell lung cancer (NSCLC) patients but are associated with immune-related adverse effects (IRAEs). Management of IRAEs may include immunosuppression (ie, corticosteroids), but there is concern that this may affect efficacy. This study evaluated the influence of IRAEs and immunosuppression for IRAEs on survival outcomes of NSCLC patients treated with PD-1 inhibitors (pembrolizumab and nivolumab).

We retrospectively examined data from Kaiser Permanente Southern and Northern California members diagnosed with NSCLC who received a PD-1 inhibitor from March 1, 2011 to September 30, 2016. Our primary goal was to evaluate the effects and management of IRAEs on survival with PD-1 inhibitors. Electronic database records were used to identify the occurrence of IRAEs, medication utilization, and death. Cox proportional hazard models were used to evaluate variables for association with increased risk of death.

A total of 662 patients were included in the study (median age = 68 years) (interquartile range 61-74). IRAEs were identified in 18% of patients, of which 62% received immunosuppression. Median overall survival was 10 months (interquartile range = 4 months to not reached). Adjusting for covariates, use of immunosuppression during PD-1 inhibitor treatment was not associated with a significantly higher risk of death (hazard ratio = 1.04, 95% confidence interval = 0.84-1.29), whereas corticosteroid use before initiating PD-1 inhibitor therapy was (hazard ratio = 1.48, 95% confidence interval = 1.14-1.91).

In a large, real-world cohort from an integrated healthcare system, use of corticosteroids prior to PD-1 inhibitors was associated with worse survival outcomes, whereas concomitant treatment was not.
In a large, real-world cohort from an integrated healthcare system, use of corticosteroids prior to PD-1 inhibitors was associated with worse survival outcomes, whereas concomitant treatment was not.
As a means of conceptualizing population health, the County Health Rankings & Roadmaps program developed a methodology to rank counties within each state on Health Outcomes and Health Factors. We built on this framework by introducing an additional application that utilized national percentile scores and population size weighting to compare counties on a national, rather than a state, level.

We created national percentile scores for 3078 US counties and used population size weighting in our calculations so that values for counties with larger populations would be weighted more heavily than values for counties with smaller populations.

We demonstrated how this application can be used to 1) compare counties nationally, 2) examine clustering and variability among counties, and 3) compare the health of states and regions. To underscore its utility, we included an example application by Kaiser Permanente. As a form of method validation, the results of this application are in line with other ranking systems (eg, US News and World Report and United Health Foundation; ρ = 0.
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