VA Connecticut Healthcare System

Guidelines recommend i.v. albumin after large-volume paracentesis to prevent postparacentesis circulatory dysfunction and acute kidney injury (AKI). However, real-world effects of albumin on paracentesis outcomes in outpatient settings are understudied. We aimed to address this using national data from a well-established cirrhosis cohort. This was a retrospective cohort study of Veterans with cirrhosis undergoing outpatient paracentesis. Albumin administration and paracentesis volumes were extracted, in addition to hospitalization for AKI within 7 days of outpatient paracentesis. Mixed-effects logistic regression identified factors associated with albumin administration and the association between albumin and incident AKI hospitalization. Among 9467 patients who received 56,941 outpatient paracentesis procedures, i.v. albumin was used 17% of the time. The use was higher with Model for End-Stage Liver Disease-Sodium; (OR: 1.02, 95% CI: 1.02-1.03, p<0.001), lower estimated glomerular filtration rate (OR: 3.06 for <30 vs. ≥90mL/min/1.73m2, 95% CI: 2.64-3.54, p<0.001), and HE (OR: 1.22, 95% CI: 1.13-1.33, p<0.001). Albumin administration was associated with lower odds of AKI-related hospitalizations (OR: 0.66, 95% CI: 0.54-0.81, p<0.001), with a greater effect observed in patients with lower estimated glomerular filtration rate (interaction p value=0.03). In a subcohort of 48,401 procedures with available dosing information, higher-dose albumin (≥6-8g/L removed) was associated with lower odds of AKI hospitalization (OR:: 0.36, 95% CI:: 0.20-0.64, p=0.001) with similar associations noted irrespective of paracentesis volume. Albumin administration after outpatient paracentesis was associated with a reduced risk of hospitalization with AKI, with a greater effect at lower estimated glomerular filtration rates. Strategies that tailor albumin administration based on intravascular volume and hemodynamics should be prospectively tested.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Cannabis use is common among those with mental health conditions, and many people report using cannabis to manage mental health symptoms. It is important for clinicians to understand the lack of clear benefits of cannabis for mental health conditions and the potential for substantial adverse effects. Overall, the potential benefits of cannabis for mental health conditions remain poorly studied. There is low-certainty evidence that Δ-9-tetrahydrocannabinol (THC)-predominant cannabis may not improve symptoms of posttraumatic stress disorder, and there is largely insufficient evidence to characterize the effects of long-term THC-predominant cannabis use on anxiety, depression, and attention-deficit/hyperactivity disorder. There is emerging low-certainty evidence that the cannabis constituent cannabidiol alone may reduce anxiety in patients with anxiety disorders. THC-predominant cannabis use holds substantial risk for adverse mental health effects, and counseling patients about these risks is crucial to promote safety. These risks include worsening mania symptoms and function in those with bipolar disorder and an increase in psychotic symptoms in those with psychotic spectrum disorders. Among people with past-year cannabis use, about 3 in 10 have cannabis use disorder (CUD), and about one-half those with CUD have moderate or severe disease with negative social, employment, or other adverse outcomes. Regular use of high THC-content products by adolescents and young adults is associated with several concerning risks, including an increased risk of psychosis (estimates range from about 2-fold to 11-fold increased risk), a higher risk of CUD, and self-harm in those with mood disorders. Cannabis use should be avoided in individuals at elevated risk of harms, including adolescents and young adults, those with bipolar or psychotic disorders, pregnant individuals, and those at risk for substance use disorders. The current evidence base is not sufficient to support the use of cannabis for the treatment of mental health conditions and demonstrates substantial risks of adverse effects. Clinicians should engage patients with mental health conditions in discussions about cannabis use because use is common, has an influence on mental health symptoms, and is likely an important modifiable risk factor for mental health conditions in some populations.

Seizures negatively affect quality of life (QoL), but the impact of seizure control and mental health on QoL over time is not well described. The aim of this study was to investigate how these factors influence the longitudinal trajectory of QoL in patients with focal epilepsy.

Use of complementary and integrative health (CIH) therapies has increased over the past two decades. Accumulating evidence supports the effectiveness of CIH therapies for a range of health outcomes and an association between CIH therapy use and reduced use of opioid therapy. To describe differences in the use of evidence-based CIH therapies among individuals with chronic pain on long-term opioid therapy (LTOT) by sociodemographic and clinical characteristics. This was an observational study using a national retrospective cohort of patients developed from Veterans Affairs (VA) electronic health record data. The sample comprised 281,903 patients receiving LTOT upon cohort entry between July 1, 2017, and December 31, 2021, with a health care encounter in one of 54 VA medical centers. CIH therapy use was defined as chart-documented use of any of eight priority CIH therapies or chiropractic care in the year prior to cohort entry. LTOT was defined as having a prescribed opioid analgesic for ≥90 consecutive days, allowing ≤30 days between fills. Sociodemographic and clinical characteristic variables were assessed as covariates of CIH therapy use. Among the full cohort, the CIH therapy use rate was 9.5%. Use increased with each cohort entry year relative to 2017. In a multivariable model, variables associated with greater odds of CIH therapy use included being female, having a musculoskeletal pain condition, obesity, opioid use disorder, anxiety, depression, post-traumatic stress disorder, and receiving services in a flagship site. Lower odds of use were associated with being older, unmarried, prescribed higher opioid doses, smoking, and rural residence. CIH therapy use has increased over time, consistent with national trends; however, differential patterns of exposure suggest the need to explore pathways to use. These may elucidate opportunities to broaden access to these evidence-based therapies for patients with chronic pain.

In 2022, over 6 million individuals in the United States were affected by opioid use disorder (OUD), and more than 81,000 died from opioid-related overdoses. This umbrella review synthesized evidence on the associations between a broad range of social determinants of health (SDoH) and OUD/overdose. An umbrella review of meta-analyses and reviews on SDoH and OUD/overdose was conducted using PubMED, PsycINFO, Embase, and Web of Science. A total of 29 reviews were deemed appropriate for inclusion. Adverse childhood experiences and unemployment were associated with OUD outcomes. In the United States, immigrant status was associated with a lower risk of OUD, though this risk increased in subsequent generations. Individuals who experienced intimate partner violence and sexual minority individuals showed high prevalence of OUD. For overdose, associations were found in unemployment, low income, high poverty, and justice system involvement. Significant increases in odds of overdose were noted among individuals experiencing homelessness, lacking private insurance, engaging in sex work for pay, or witnessing an overdose. This study identified SDoH associated with OUD outcomes and overdose risk, with findings having implications from a public health perspective for clinical practice, public health policy, and research priorities. There is a need for meta-analyses to clarify the magnitude of SDoH influences on OUD/overdose, with the goal of informing targeted interventions to reduce opioid-related morbidity and mortality. The most comprehensive umbrella review to date on intersections among SDoH, OUD outcomes, and overdose risk.

The Food and Drug Administration's warning that transmucosal buprenorphine, a partial opioid agonist used to treat opioid use disorder and chronic pain, may cause dental disease opens questions about potential class-wide adverse effects involving more widely prescribed opioid analgesics. This was a retrospective matched national cohort study of patients in care at the Department of Veterans Affairs (VA) between October 2010-September 2019. Patients prescribed LTOT were matched 1:2 to patients not prescribed LTOT on age, sex, service region, and VA dental coverage. Cox regression models estimated the association between LTOT and a composite infection-related dental outcome (CIDO). Sensitivity analyses excluded patients with cancer, restricted to patients with comprehensive dental coverage, and to patients with ≥180 days of follow-up time, respectively. The cohort comprised 2,173,435 patients including 787,825 (36%) receiving LTOT; 612,101 (28%) experienced CIDO. In both simple and multivariable regression models, LTOT exposure was associated with greater CIDO risk; HR (95% CI) =1.24 (1.23, 1.25); aHR (95% CI) =1.08 (1.07, 1.08), respectively; p < 0.001. Sensitivity analyses showed similar results except among patients with full dental coverage for whom CIDO rates were substantially higher and LTOT was not statistically significantly associated with risk. he observed positive association between LTOT and CIDO in this large VA sample may inform patient-provider discussions and decision-making around use of LTOT. High CIDO rates among patients with full VA dental coverage may reflect their unique vulnerability to dental infection associated with service-related dental or disabling conditions. Limitations include risk for ascertainment bias, unclear generalizability to a broader clinical population, and the potential for residual confounding.

This study was undertaken to identify gaps in cluster headache management, highlight patient-prioritized research needs, and assess patient interest in, and preferences for, clinical trial participation. Many people with cluster headache still lack effective treatment options to control or prevent attacks. There is a critical need for more studies, particularly clinical trials, in this field. To design and conduct successful trials, it is essential to identify priority research areas, allocate resources effectively, and ensure patient engagement and support. This study was an online survey conducted among Australian adults with self-reported cluster headache. Participants were recruited using a multi-channel approach, including direct outreach by clinicians, support from patient advocacy groups, and broad social media distribution. It collected data on demographics, treatment experiences, and perspectives on future research, including research priorities, and preferred outcomes and interventions. Additionally, participants' interest in joining clinical trials was assessed to help identify potential candidates for future studies. Of the 219 individuals who began the survey, 17 (8%) were excluded due to providing no responses beyond demographic data or reporting no cluster headache diagnosis by a healthcare professional. The final sample consisted of 202 participants, with an average age of 46 years, 77% aged 25-54 years, 55% male, 72% had been living with cluster headache for more than 10 years, and 29% reported attacks occurring almost every month throughout the year. A quarter of participants had not followed up with a healthcare provider for cluster headache management when they completed the survey. Among those who sought care (n = 145 [72%]), general practitioners were the most frequently consulted (86%), followed by neurologists (66%). Treatments were considered "not at all effective" or "somewhat ineffective" by 35% of all participants, while 27% reported only partial effectiveness. The main treatment challenges were ineffectiveness (74%), side effects (54%), cost (53%), and difficulties with access (39%). Among the 202 participants, 126 (62%) indicated interest in participating in future cluster headache trials, while 26 (13%) responded with "maybe." Psilocybin was the highest-ranked treatment in terms of participants who were "very interested," with 66% selecting this option. The combined proportion of participants who were "very interested" or "interested" was 84% for combination therapies, 82% for psilocybin, 71% for medical devices, and 66% for anti-CGRP treatments. Participants with reported cluster headache highlighted inadequate treatment options, emphasized the need for further research, and expressed interest in future clinical trials, particularly those involving psilocybin or combination therapies.

Opioids remain a central element of perioperative pain management despite increased utilization of multimodal adjuvant strategies intended to reduce their use. Contemporary use of methadone and buprenorphine, both conceived as opioid analgesics, is dominated by their essential roles in the treatment of opioid use disorder. Compared to usual care opioids, however, they provide improved post-operative pain control while reducing analgesic requirements. These findings argue for their expanded role within perioperative multimodal analgesia strategies.