A review of pruritus in pregnancy

Pruritus is a common dermatologic complaint during pregnancy. Pruritus is reported by 23-38% of women during pregnancy, and 2% report severe pruritus. In addition to interfering with sleep and reducing overall quality of life during pregnancy, pruritus may be the first, or only, symptom of an underlying disorder that may impact maternal and fetal outcomes. It is therefore critical for all providers caring for pregnant women to be familiar with pregnancy-specific and non-specific conditions associated with pruritus to most effectively manage this unique population. In this review, we discuss clinical classification of pruritus, a practical approach to the differential diagnosis of pruritus in pregnancy, and focus on updates in the clinical features, diagnosis, management, and prognosis of pregnancy-specific causes of pruritus.

Opiate Prescriptions at Discharge Are Not Associated with Early Readmissions in Acute Pancreatitis

BACKGROUND

Early readmissions in acute pancreatitis (AP) are common. The impact of opiate prescriptions on readmissions is unknown.

AIMS

To determine whether the prescription of opiates at hospital discharge and the dose prescribed are associated with early readmissions in AP.

METHODS

Direct admissions from the Emergency Department (ED) for AP from September 1, 2013, to August 31, 2016 were identified. Opiate prescription was defined as a new prescription at discharge in an opiate-naïve patient. Early readmission was ED visit or hospitalization within 30 days for an AP-related reason. Multivariable logistic regression was performed, adjusted for age, Charlson Comorbidity Index, pancreatic necrosis, baseline opiate use, non-opiate analgesics, and pain score at discharge.

RESULTS

A total of 318 AP patients were identified; the overall early readmission rate was 18%. One hundred and twenty-one (38%) were prescribed opiates at discharge, and 22% had an early readmission. One hundred and ninety-seven (62%) were not prescribed opiates, and 16% had an early readmission. Median opiate dose was 48 mg (24-h morphine equivalents). On multivariable analysis, neither the prescription of opiates (OR 1.2, 95% CI 0.6-2.4, p = 0.55) nor the dose of opiates (OR 0.99, 95% CI 0.99-1.00, p = 0.39) was associated with early readmission. In subset analysis of patients discharged with an opiate prescription, those on opiates at baseline were significantly more likely to have an early readmission (OR 4.19, 95% CI 1.04-16.94, p = 0.04).

CONCLUSIONS

In AP patients, neither prescription of opiates at discharge nor prescribed dose was associated with early readmission. Patients on opiates at baseline discharged with an opiate prescription were more likely to have an early readmission.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

BACKGROUND

Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

RESULTS

Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

CONCLUSIONS

Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Shared Responsibility: Massachusetts Legislators, Physicians, and An Act Relative to Substance Use Treatment, Education, and Prevention

Recent passage of the Massachusetts law, An Act Relative to Substance Use, Treatment, Education, and Prevention, represents an admirable public health approach to substance use disorder (SUD), a stigmatized chronic disease that affects some of society's most vulnerable people. With its seven-day supply limit on first-time opioid prescriptions, this legislation takes an unusual approach to state government involvement in health care. By intervening in individual physicians' practices, state legislators have entered a space traditionally reserved for clinical teams. The seven-day supply limit and the process through which it was developed highlight competing priorities and dialogue between physicians and legislators, limits of physician self-regulation, and standards of evidence in policy making and health care. Addressing these issues requires both physicians and legislators to recognize and fulfill new responsibilities in order to better assist the populations they serve.

Behavioral health integration in primary care at Brigham and Women׳s Advanced Primary Care Associates, South Huntington

Of the many problems facing the US healthcare system, the shortage of behavioral health providers in outpatient settings is particularly profound. To address this issue, Boston׳s Brigham and Women׳s Hospital identified ways to incorporate behavioral health into primary care when it opened the South Huntington Primary Care clinic in August 2011. When the needs of its patients were more complex than anticipated, the clinic created assessment tools and refined care processes to identify, triage, and monitor patients with mental illness. Key insights from the South Huntington experience include. • Hiring for roles instead of training can decrease costs of implementation. • A process for reflection, assessment, and adaptation is a critical component of innovation. • Innovations must adapt to the specific needs of the local community. • Innovations are most effective when they reflect the capabilities of local providers.