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Insulin is recommended as first-line pharmacologic therapy for gestational diabetes (GDM); however, glyburide and metformin are often used. This study aimed to identify the most commonly prescribed agents for treating GDM, along with the maternal and fetal outcomes associated with their use. Electronic medical records were used to identify the medications prescribed for GDM at a large health system. Data were collected comparing medication failure rate, maternal weight gain, and incidence of fetal macrosomia, neonatal hypoglycemia, and premature delivery between the agents used. Of the 368 patients who met the inclusion criteria, 76.9% were initiated on glyburide, 13.6% were initiated on metformin, 8.2% were initiated on insulin, and 1.4% were initiated on a combination of glyburide and metformin. Glyburide was associated with less medication failure compared to insulin and metformin. There was no significant difference in maternal weight gain, fetal macrosomia, or neonatal hypoglycemia between the three classes of medications. However, recipients of basal and bolus insulin had a higher rate of preterm delivery compared to recipients of glyburide and metformin. Our findings suggest that glyburide and metformin are frequently prescribed over insulin as the initial treatment for GDM and appear to be safe and effective alternatives. [ABSTRACT FROM AUTHOR]

In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing. [ABSTRACT FROM AUTHOR]

Our hypothesis was that patients managed with noninvasive ventilation (NIV) on the wards could be risk-stratified with initial pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratios and tidal volumes (Vte). A prospective study of consecutive patients with acute respiratory failure requiring NIV on the wards was conducted. A multivariate logistic regression model and a negative binomial regression model were used. A total of 403 patients (55.8% women) had a mean age of 65.0 ± 14.9 years with a mean body mass index of 32.1 ± 11.1 kg/m2. The 28-day mortality was 14.1%, and the intubation rate was 16.1%. Pneumonia was associated with the highest 28-day mortality (22.5%) and rate of intubation (36.7%) when compared with chronic obstructive pulmonary disease (4.4% and 7.3%) or congestive heart failure (22.2% and 13.4%). The SpO2/FiO2 groups were <214 (26.6%), 214 -357 (66.0%), and ≥357 (7.4%). Those in the SpO2/FiO2 < 214 group had a higher 28-day mortality rate (odds ratio [OR] = 8.19; 95% confidence interval [CI] 1.02 -65.7), intubation rate (OR = 3.7; 95% CI 1.1 -12.1), intensive care unit admission rate (OR = 2.9; 95% CI 1.2 -7.4), and length of stay (relative risk = 2.0; 95% CI 1.3 -3.0). A Vte/predicted body weight <7.7 mL/kg was associated with increased intubations (OR = 3.1; 95% CI 1.3 -7.4), intensive care unit admissions (OR = 2.5; 95% CI 1.3 -4.6), and 30-day readmissions (OR = 2.9; 95% CI 1.2 -6.8). In conclusion, in patients without acute respiratory distress syndrome who had acute respiratory failure managed with noninvasive ventilation on the wards, severe hypoxemia as assessed by a simple SpO2/FiO2 ≤ 214 was associated with poor outcomes. [ABSTRACT FROM AUTHOR]