Research Spotlight

Shao, Q., Rascati, K.L., Lawson, K.A., Wilson, J.P., Shah, S. and Garrett, J.S. (2021). “Impact of emergency department opioid use on future health resource utilization among patients with migraine.” Headache 61(2): 287-299.

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OBJECTIVE: The purpose of this study was to evaluate the subsequent health resource utilization (HRU) between patients with migraine who received opioid medications at their emergency department (ED) visits (“opioid recipients”) versus patients with migraine who did not receive opioid medications at their ED visits (“non-recipients”). BACKGROUND: Previous studies have found that opioid use is common among patients with migraine at emergency settings. Medication overuse, especially the use of opioids, is associated with migraine progression, which can ultimately lead to substantial health resource use and costs. There is limited evidence on opioid use specifically in emergency settings and its impact on future HRU among people with migraine. METHOD: This retrospective cohort study used electronic health record data from the Baylor Scott & White Health between December 2013 and April 2017. Adult patients who had at least 6 months of continuous enrollment before (baseline or pre-index) and after (follow-up) the first date they had an ED visit with a diagnosis of migraine (defined as index date) were enrolled in the study. Opioid use and HRU during follow-up period between opioid recipients and non-recipients were summarized and compared. RESULTS: A total of 788 patients met the eligibility criteria and were included in this study. During the 6-month follow-up period, compared to patients with migraine who were non-recipients at their index ED visits, opioid recipients had significantly more all-cause (3.6 [SD = 6.3] vs. 1.9 [SD = 4.8], p < 0.0001) and migraine-related (1.6 [SD = 4.2] vs. 0.6 [SD = 2.1], p < 0.0001) opioid prescriptions (RXs), and more all-cause (2.6 [SD = 4.3] vs. 1.6 [SD = 2.6], p = 0.002) and migraine-related (0.6 [SD = 1.4] vs. 0.3 [SD = 0.8], p = 0.001) ED visits. In addition, opioid recipients had higher risk of future migraine-related ED visits controlling for covariates (HR = 1.49, 95% CI = 1.09-2.03, p = 0.013). Factors that were significantly (p < 0.05) related to future migraine-related ED visits include previous opioid use (HR = 2.12, 95% CI = 1.24-3.65, p = 0.007), previous ED visits (HR = 2.38, 95% CI = 1.23-4.58, p = 0.010), hypertension (HR = 1.46, 95% CI = 1.07-2.00, p = 0.017), age between 45 and 64 years (HR = 0.68, 95% CI = 0.48-0.97, p = 0.033), female sex (HR = 1.82, 95% CI = 1.12-2.86, p = 0.015), and tobacco use disorder (HR = 1.45, 95% CI = 1.07-1.97, p = 0.017). Sub-analyses were restricted to the group of patients who were opioid naïve at baseline (n = 274, defined as having ≤1 opioid RXs during the 6-month pre-index period). Patients who were baseline opioid naïve but received opioids during their index ED visits were more likely to have future migraine-related ED visits compared to patients who were baseline opioid naïve and did not receive any opioids during their index ED visits, controlling for covariates (HR = 2.90, 95% CI = 1.54-5.46, p = 0.001). CONCLUSION: Opioid use among patients with migraine presenting to the ED is associated with increased future HRU, which highlights the need for optimizing migraine management in emergency settings.

Wu, M.J., Chung, J.R., Kim, S.S., Jackson, M.L., Jackson, L.A., Belongia, E.A., McLean, H.Q., Gaglani, M., Reis, M., Beeram, M., Martin, E.T., Monto, A.S., Nowalk, M.P., Zimmerman, R., Santibanez, T.A., Singleton, J.A., Patel, M. and Flannery, B. (2021). “Influenza vaccination coverage among persons seeking outpatient medical care for acute respiratory illness in five states in the United States, 2011-2012 through 2018-2019.” Vaccine Feb 15;S0264-410X(21)00106-7. [Epub ahead of print].

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BACKGROUND: In the United States (U.S.), annual influenza vaccination has been recommended for all persons aged ≥6 months with the Healthy People 2020 coverage target of 70%. However, vaccination coverage has remained around 42-49% during the past eight influenza seasons. We sought to quantify influenza vaccination coverage and factors associated with vaccination in persons seeking outpatient medical care for an acute respiratory illness (ARI). METHODS: We enrolled outpatients aged ≥6 months with ARI from >50 U.S. clinics from 2011 to 2012 through 2018-2019 influenza seasons and tested for influenza with molecular assays. Vaccination status was based on documented receipt of the current season’s influenza vaccine. We estimated vaccination coverage among influenza-negative study participants by study site, age, and season, and compared to state-level influenza coverage estimates in the general population based on annual immunization surveys. We used multivariable logistic regression to examine factors independently associated with receipt of influenza vaccines. RESULTS: We enrolled 45,424 study participants with ARI who tested negative for influenza during the study period. Annual vaccination coverage among influenza-negative ARI patients and the general population in the participating states averaged 55% (range: 47-62%), and 52% (range: 46-54%), respectively. Among enrollees, coverage was highest among adults aged ≥65 years (82%; range, 80-85%) and lowest among adolescents aged 13-17 years (38%; range, 35-41%). Factors significantly associated with non-vaccination included non-White race, no college degree, exposure to cigarette smoke, absence of high-risk conditions, and not receiving prior season influenza vaccine. CONCLUSIONS: Influenza vaccination coverage over eight seasons among outpatients with non-influenza respiratory illness was slightly higher than coverage in the general population but 15% lower than national targets. Increased efforts to promote vaccination especially in groups with lower coverage are warranted to attain optimal health benefits of influenza vaccine.

Boccia, M.L., Anyanda, E.I. and Fonkem, E. (2021). “A Preliminary Report on Quality of Life and Sexual Function in Brain Tumor Patients.” J Sex Med Feb 6;S1743-6095(21)00174-0. [Epub ahead of print].

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BACKGROUND: As tumor treatment has advanced, patients are surviving and returning to productive lives. Quality of life (QoL) has become a significant consideration in the care of survivors. The 2005 Institute of Medicine Cancer Survivorship Care Planning requires the inclusion of information on the possible effects of cancer on marital/partner relationship and sexual functioning, among other factors related to QoL. AIM: The purpose of this study is to explore the quality of life and the rates and types of sexual dysfunction among brain tumor patients. METHODS: Patients were recruited from a neuro-oncology practice and given a QoL questionnaire (FACT-Br). Women were given the Female Sexual Function Index (FSFI). Men were given scales to assess premature ejaculation (PE), erectile dysfunction (ED), and Peyronie’s disease. In addition, information about the site and type of tumor and treatment (surgery, radiation, chemotherapy) was collected. Descriptive statistics, as well as T-tests and ANOVAs, were used to analyze the data. OUTCOMES: Study outcomes were obtained utilizing clinical cutoff scores for the sexual function questionnaires. RESULTS: Data were collected on 50 patients. The most common form of brain tumor in this sample was glioblastoma. The frontal lobe was the most common location of tumors. There was significantly more sexual dysfunction than previously reported, with 66% of the sexually active women meeting the criteria for total FSFI. Of the men who were sexually active, 60% reported some ED, and 80% reported PE. CLINICAL TRANSLATION: The current findings contribute to supporting the assertion that it is important for physicians to discuss with their cancer patients the issues related to sexual function. STRENGTHS & LIMITATIONS: A primary strength of this study is the utilization of validated assessments of sexual function. The primary limitation is the sample size, particularly for men. CONCLUSION: Our capacity to address the sexual function concerns of patients is dependent on our understanding of the types of difficulties encountered. This study contributes information about sexual function, a major contributor to QoL, in patients with brain tumor diagnosis and treatment.

Fawaz, B., Chamseddin, B.H. and Griffin, J.R. (2021). “Defining the role of mirtazapine in the treatment of refractory pruritus.” J Dermatolog Treat 32(2): 132-136.

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BACKGROUND/OBJECTIVE: Mirtazapine has traditionally been used for the treatment of major depressive disorder, with an added benefit in patients who have comorbid insomnia or anxiety. Recent studies describe its usefulness in treating refractory pruritus of various causes as well. Our goal is to better define the use of mirtazapine in the treatment of refractory pruritus. METHOD: Through a thorough literature review of PubMed, we identified all reports of the use of mirtazapine for pruritus. RESULTS: Upon examination of 8 supporting articles, we found mirtazapine has quality evidence for the treatment of intra-thecal morphine-induced pruritus. Mirtazapine may also be effective in treating pruritus related to various other conditions, including psoriasis, atopic dermatitis, cutaneous malignancies (primary or metastatic), hematologic malignancies (lymphomas and leukemias), liver failure, renal failure, cholestasis, as well as pruritus of unknown origin. CONCLUSIONS: Mirtazapine plays a role in treatment for intra-thecel morphine-induced pruritis yet high-quality trials are needed to confirm its efficacy in other dermatologic conditions.

Palmer, B.F., Carrero, J.J., Clegg, D.J., Colbert, G.B., Emmett, M., Fishbane, S., Hain, D.J., Lerma, E., Onuigbo, M., Rastogi, A., Roger, S.D., Spinowitz, B.S. and Weir, M.R. (2021). “Clinical Management of Hyperkalemia.” Mayo Clin Proc 96(3): 744-762.

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Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K(+)) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K(+) monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K(+)-binding agents. Monitoring serum K(+) should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K(+) binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K(+) binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K(+)-binding agents requires further study to establish whether stringent dietary K(+) restrictions are needed in patients receiving K(+)-binder therapy. Individualized monitoring of serum K(+) among patients with an increased risk of hyperkalemia and the use of newer K(+)-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.