Notes

SARS-CoV-2-Associated Obliterative Arteritis Causing Massive Testicular Infarction.
Eating disorders are one of the most common causes of pediatric hospitalizations due to primary mental health diagnoses. The purpose of this article is to discuss the challenges clinical psychologists face in working with patients with eating disorders and their families during medical admissions. Using the Psychiatry Consultation Service at a tertiary pediatric academic medical center in the Northeast as a framework, authors present the responsibilities of clinical psychologists on this service and their role within the larger, interdisciplinary team. Topics addressed also include systemic challenges, medical and psychiatric comorbidities, and differential psychiatric diagnoses. Case examples are provided to highlight various challenges as well as potential solutions and approaches. Clinical implications, limitations, and directions for future research are also discussed.
In the current opioid epidemic, opioid addiction and overdose deaths are a public health crisis. Researchers have uncovered other concerning findings related to opioid use, such as the association between prescribed opioids and respiratory infection, including pneumonias. Potential mechanisms include the immunosuppressive effects of certain opioids, respiratory depression, and cough suppression. We conducted a systematic review assessing whether prescribed opioid receipt is a risk factor for community-acquired pneumonia (CAP).

A systematic literature search of published studies was conducted using Ovid MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Web of Science, AMED, and CINAHL from database inception through March 11, 2020. We included any clinical trial, cohort, or case-control study that reported an association between prescribed opioid receipt and CAP in adults. Two reviewers independently performed data extraction and quality assessment using the Newcastle-Ottawa Qualits examined post-operative patients and patients with chronic medical conditions. Further research is needed to examine the impact of opioids on the incidence of CAP in an otherwise healthy population.
Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence.

This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults.

A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019.

Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes.

A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. find more BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification.

Patient-level CW compliance.

CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%).

The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics.

NCT03409523.
NCT03409523.
There is no effective therapy for COVID-19. Hydroxychloroquine (HCQ) and chloroquine (CQ) have been used for its treatment but their safety and efficacy remain uncertain.

We performed a systematic review to synthesize the available data on the efficacy and safety of CQ and HCQ for the treatment of COVID-19.

Two reviewers searched for published and pre-published relevant articles between December 2019 and 8 June 2020. The data from the selected studies were abstracted and analyzed for efficacy and safety outcomes. Critical appraisal of the evidence was done by Cochrane risk of bias tool and Newcastle Ottawa Scale. The quality of evidence was graded as per the GRADE approach.

We reviewed 12 observational and 3 randomized trials which included 10,659 patients of whom 5713 received CQ/HCQ and 4966 received only standard of care. The efficacy of CQ/HCQ for COVID-19 was inconsistent across the studies. Meta-analysis of included studies revealed no significant reduction in mortality with HCQ use [RR 0.98 95% CI 0.66-1.46], time to fever resolution (mean difference - 0.54 days (- 1.19-011)) or clinical deterioration/development of ARDS with HCQ [RR 0.90 95% CI 0.47-1.71]. There was a higher risk of ECG abnormalities/arrhythmia with HCQ/CQ [RR 1.46 95% CI 1.04 to 2.06]. The quality of evidence was graded as very low for these outcomes.

The available evidence suggests that CQ or HCQ does not improve clinical outcomes in COVID-19. Well-designed randomized trials are required for assessing the efficacy and safety of HCQ and CQ for COVID-19.
The available evidence suggests that CQ or HCQ does not improve clinical outcomes in COVID-19. Well-designed randomized trials are required for assessing the efficacy and safety of HCQ and CQ for COVID-19.
High clinical variation has been linked to decreased quality of care, increased costs, and decreased patient satisfaction. We present the implementation and analysis of a peer comparison intervention to reduce clinical variation within a large primary care network.

Evaluate existing variation in radiology ordering within a primary care network and determine whether peer comparison feedback reduces variation or changes practice patterns.

Radiology ordering data was analyzed to evaluate baseline variation in imaging rates. A utilization dashboard was shared monthly with providers for a year, and imaging rates pre- and post-intervention were retrospectively analyzed.

Providers within the primary care network spanning 1,358,644 outpatient encounters and 159 providers over a 3-year period.

The inclusion of radiology utilization data as part of a provider's monthly quality and productivity dashboards. This information allows providers to compare their practice patterns with those of their colleagues.

Weicability in other clinical areas.
Peer comparison feedback can shape provider imaging behavior even in the absence of targets or financial incentives. Peer comparison is a low-touch, low-cost intervention for influencing provider ordering and may have applicability in other clinical areas.
Despite evidence of effectiveness, most US hospitals do not deliver hospital-based addictions care. ECHO (Extension for Community Healthcare Outcomes) is a telementoring model for providers across diverse geographic areas. We developed and implemented a substance use disorder (SUD) in hospital care ECHO to support statewide dissemination of best practices in hospital-based addictions care.

Assess the feasibility, acceptability, and effects of ECHO and explore lessons learned and implications for the spread of hospital-based addictions care.

Mixed-methods study with a pre-/post-intervention design.

Interprofessional hospital providers and administrators across Oregon.

A 10-12-week ECHO that included participant case presentations and brief didactics delivered by an interprofessional faculty, including peers with lived experience in recovery.

To assess feasibility and acceptability, we collected enrollment, attendance, and participant feedback data. To evaluate ECHO effects, we used pre-/post-ECHO aceptable. Findings may be useful to health systems, states, and regions looking to expand hospital-based addictions care.
A statewide, interprofessional SUD hospital care ECHO was feasible and acceptable. Findings may be useful to health systems, states, and regions looking to expand hospital-based addictions care.When making an appointment, patients are generally unaware of how much clinician time is available to address their concerns. Similarly, the primary care clinician is often unaware of what the patient expects to accomplish during the visit, leading to uncertainty about how much time they can allot to each sequentially appearing concern, and whether they can reasonably expect to address necessary preventive services and chronic disease management. Neither patient nor clinician expectations can be adequately managed through standardized scheduling templates, which assign a fixed appointment length based on a single stated reason for the visit. As such, standardized appointment scheduling may contribute to inefficient use of valuable face-to-face time, patient and clinician dissatisfaction, and low-value care. Herein, we suggest several potential mechanisms for improving the scheduling process, including (1) entrusting scheduling to the primary care team; (2) advance visit planning; (3) pro-active engagement of ancillary team members including behavioral health, nursing, social work, and pharmacy; and (4) application of innovative, technologically advanced solutions such as telehealth and artificial intelligence to the scheduling process. These changes have the potential to improve efficiency, patient and clinician satisfaction, and health outcomes, while decreasing low-value testing and return visits for unaddressed concerns.
Cash prices for prescription drugs vary among community pharmacies in the USA. GoodRx is a discount platform that provides coupons for use in community pharmacies without a membership requirement. Analytical pharmacy is a new type of pharmacy that tests drugs before dispensing to verify medication quality.

To compare undiscounted and GoodRx-discounted cash prices for common cardiovascular (CV) drugs by pharmacy type.

A cross-sectional study.

GoodRx-discounted and GoodRx-undiscounted cash price data; analytical pharmacy cash price data (all data collected in July 2020).

GoodRx cash price data for 30 units of 41 generic and 16 brand-name common cardiovascular medications at mass merchandiser, regional supermarket, two national chains, and analytical pharmacy (only one of its kind in the USA).

The average (SD) undiscounted generic CV medication cash price was $42.41 (44.1). The average GoodRx-discounted generic CV medication cash prices were $11.01 (8.6), $9.88 (6.7), $17.85 (10.5), and $21.73 (14.1)es.
GoodRx-discounted cash prices of generic CV medications were significantly lower than undiscounted cash prices at supermarket, mass merchandiser, and national chain pharmacies. Analytical pharmacy cash prices too were significantly lower than traditional pharmacy undiscounted cash prices. GoodRx-discounted prices for brand-name CV medications did not differ significantly from undiscounted cash prices and between pharmacy types.
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