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Background: Although cardiometabolic diseases are leading causes of morbidity and mortality in the United States, computerized tools for risk assessment of cardiometabolic disease are rarely integral components of primary care practice. Embedding cardiometabolic disease staging systems (CMDS) into computerized clinical decision support systems (CDSS) may assist with identifying and treating patients at greatest risk for developing cardiometabolic disease. Objective: This study aimed to explore the current approach to medical management of obesity and the need for CMDS designed to aid medical management of people living with obesity, at risk of being obese, or diabetic at the point of care. Methods: Using a general inductive approach, this qualitative research study was guided by an interpretive epistemology. The method included semistructured, in-depth interviews with primary care providers (PCPs) from university-based community health clinics. The literature informed the interview protocol and included questions on PCPs' experiences and the need for a tool to improve their ability to manage and prevent complications from overweight and obesity. Results: PCPs (N=10) described their current approaches and emphasized behavioral treatments consisting of combined diet, physical activity, and behavior therapy as the first line of treatment for people who were overweight or obese. Results suggest that beneficial features of CDSS include (1) clinically relevant and customizable support, (2) provision of a comprehensive medical summary with trends, (3) availability of patient education materials and community resources, and (4) simplicity and ease of navigation. Conclusions: Implementation of a CMDS via a CDSS could enable PCPs to conduct comprehensive cardiometabolic disease risk assessments, supporting clinical management of overweight, obesity, and diabetes. Results from this study provide unique insights to developers and researchers by identifying areas for design optimization, improved end user experience, and successful adoption of the CDSS. [ABSTRACT FROM AUTHOR]

Background: Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage.Materials and Methods: Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA.Results: 776,766 patients were included in the analysis. The population receiving PCT placement was on average 16 years older (69.9 vs 53.6 years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically.Discussion: Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities. [ABSTRACT FROM AUTHOR]

Aim: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia)., Methods: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate., Structure: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed., (Copyright © 2024 American College of Cardiology Foundation and the American Heart Association, Inc. Published by Elsevier. Published by Elsevier Inc. All rights reserved.)

Introduction: Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA., Methods: The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay., Results: Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001)., Conclusions: NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM., (Copyright © 2024. Published by Elsevier Inc.)

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States and worldwide. Medical management of known modifiable risk factors, such as dyslipidemia, hypertension, and diabetes, is a key aspect to its treatment. Unfortunately, there are substantial sex-based differences in the treatment of ASCVD that result in poor medical management and worse clinical outcomes. The objective of this systematic review was to summarize known disparities in the medical management of ASCVD in females. We included prior studies with specific sex- and sex-based analyses regarding the medical treatment of the following three major disease entities within ASCVD: cerebrovascular disease, coronary artery disease, and peripheral artery disease. A total of 43 articles met inclusion criteria. In our analysis, we found that females were less likely to receive appropriate treatment of dyslipidemia or be prescribed antithrombotic medications. However, treatment differences for diabetes and hypertension by sex were not as clearly represented in the included studies. In addition to rectifying these disparities in the medical management of ASCVD, this systematic review highlights the need to address larger issues, such as underrepresentation of females in clinical trials, decreased access to care, and underdiagnosis of ASCVD to improve overall care for females., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Coagulation disorders account for a high incidence of death in the U.S. due to stroke, myocardial infarction, and venous thromboembolism. In the past few years, numerous agents have been brought to market for the treatment of thromboembolism or prevention of thromboembolism. Similar to warfarin, these agents can cause bleeding disorders, which may exacerbate dental care treatment plans. This literature review examines the newer agents for the treatment of thromboembolism disorders, common side effects and drug interactions, the specific medical conditions each agent treats, and the dental perspective on how to medically management patients prescribed these medications. [ABSTRACT FROM AUTHOR]

Introduction A 2009 Government Accounting Office (GAO) report, along with numerous published studies, documented that many workplace injuries are not recorded on employers' recordkeeping logs required by the Occupational Safety and Health Administration (OSHA) and consequently are under-reported to the Bureau of Labor Statistics (BLS), resulting in a substantial undercount of occupational injuries in the United States. Methods OSHA conducted a Recordkeeping National Emphasis Program (NEP) from 2009 to 2012 to identify the extent and causes of unrecorded and incorrectly recorded occupational injuries and illnesses. Results OSHA found recordkeeping violations in close to half of all facilities inspected. Employee interviews identified workers' fear of reprisal and employer disciplinary programs as the most important causes of under-reporting. Subsequent inspections in the poultry industry identified employer medical management policies that fostered both under-reporting and under-recording of workplace injuries and illnesses. Conclusions OSHA corroborated previous research findings and identified onsite medical units as a potential new cause of both under-reporting and under-recording. Research is needed to better characterize and eliminate obstacles to the compilation of accurate occupational injury and illness data. Practical applications Occupational health professionals who work with high hazard industries where low injury rates are being recorded may wish to scrutinize recordkeeping practices carefully. This work suggests that, although many high-risk establishments manage recordkeeping with integrity, the lower the reported injury rate, the greater the likelihood of under-recording and under-reporting of work-related injuries and illnesses. [ABSTRACT FROM AUTHOR]

Introduction: Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States., Methods: Optum's de-identified Clinformatics ® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models., Results: A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8 years vs. 74.2 years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI) = 1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI) = 1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD., Conclusions: Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis., (© 2023. The Author(s).)

Background: Bariatric surgery is being performed with increasing frequency in the USA as a definitive treatment for morbid obesity and associated comorbidities. Management strategies of type 2 diabetes mellitus (T2DM) and hypertension (HTN) medications in sleeve gastrectomy (SG) patients postoperatively are unclear, specifically in the immediate postoperative period and 6 months following surgery. Methods: From 01 June 2010 to 30 June 2011, at a single military medical facility, a retrospective review of 88 consecutive SG patients was conducted to examine the postoperative medical management of HTN and T2DM. Patient's HTN and T2DM medication regimens were evaluated for 6 months postoperatively. Categorical data was analyzed using chi-square, and continuous data was compared using the Student t test. Statistical analyses were completed with Stata, version 12. Results: Fifty patients were prescribed an average of 2.21 HTN medications at baseline which was reduced to an average of 1.23 ( p < 0.01) medications per patient at 1 month. Twenty-four patients received an average of 1.41 oral T2DM medications with a reduction to 0.70 ( p < 0.01) on average at 1 month postoperatively. Medication changes persisted throughout the 6-month follow-up. Among T2DM patients requiring insulin therapy, the mean insulin dose was 42.1 units reduced to 16.8 units immediately postoperatively ( p < 0.01) which persisted at 1 month. At 6 months, the mean insulin dose was 13.3 units. Conclusions: Medication adjustments for HTN and T2DM made immediately in the postoperative period following SG persisted throughout the 6-month follow-up period and in some patients, required further adjustments. [ABSTRACT FROM AUTHOR]

Peyronie's disease ( PD) is a poorly understood clinical entity. We performed an in-depth analysis of the knowledge base and current practice patterns of urologists in the United States. A 46-question instrument was created by two experienced PD practitioners and emailed to current American Urology Association members nationally. Questions were either multiple-choice or used a visual analogue scale. Responses regarding treatment options were answered by ranking a list of utilized therapies by preference. Data were aggregated and mean values for each category compiled. Responses were received from 639 urologists (67% in private practice). Almost all (98%) reported seeing PD patients with regularity. Twenty-six percent believed PD prevalence is ≤1%, a small fraction (5%) reporting prevalence as ≥10%. Only 3% referred patients to a subspecialist in PD. Twenty-six percent believed PD is a condition that does not warrant any treatment. The preferred initial management was with oral agents (81%). Of those who used intralesional injections as first line, verapamil was most commonly selected (67%). Seventy-nine percent perform surgery for PD with 86% reporting the optimal timing at ≥12 months after onset of symptoms. Seventy percent perform penile plication, most commonly the Nesbit technique (54%), 61% perform implant surgery and 37% reported performing plaque incision/excision and grafting. Although PD is now a more recognized condition, there are still large variances in knowledge and management strategies. Prospective clinical studies are needed to elucidate standardized management guidelines and a more cohesive strategy to manage this common disease. [ABSTRACT FROM AUTHOR]

Background: The thyroid eye disease (TED) treatment landscape is rapidly evolving. How new treatment options have impacted practice is unknown. Methods: We conducted a cross-sectional electronic survey of American and European Thyroid Association members between June 2 and June 30, 2021. The survey included TED questions about resources for its management, index cases for different severities and presentations of TED, barriers for the management of TED, and participants' concerns about TED. We classified respondents into three geographic categories: North America, Europe, or other regions. Results: Two hundred fifty-two eligible participants started the survey (15% response rate), and 227 completed it. Participants were mostly men (50.2%, 114/227), white (79.7%, 181/227), endocrinologists with a thyroid focus (66.1%, 150/227), practicing in a tertiary academic center (46.7%, 106/227), caring for 10 or more TED patients over the last 12 months (40.5%, 92/227), and reported not having a multidisciplinary TED clinic in their institution (52.8%, 120/227). The majority reported that new TED cases per annum have not changed in the past 10 years (47.5%, 108/227), and that TED patients are found in practice during the management of hyperthyroidism (41.8%, 95/227). For mild active TED, participants from Europe reported a higher use of selenium (73%[96/132] vs. 32%[20/62] of respondents from North America and 24%[8/33] of respondents from other regions). For moderate-to-severe active TED, there was a modest preference for teprotumumab as first-line therapy (37%, 23/62) among North American participants and intravenous (IV) steroids (73%[96/132], and 42%[14/33]) for participants from Europe and other regions, respectively. These treatment preferences did not change in patients with moderate-to-severe active TED with poorly controlled diabetes. In contrast, participants from the three geographic categories preferred IV steroids for optic neuropathy and women planning pregnancy. The three top "very important" concerns about TED management according to participants were: the cost of TED treatment (31.3%, 71/227), lack of effective TED treatments (19.8%, 45/227), and difficulty in predicting whether TED will develop (18.9%, 43/227). Conclusions: There is a marked geographic practice variation in the management of TED. Clinicians' concerns about TED management demand ongoing research on more effective treatment, TED predictive tools, and policy changes to improve the affordability of new TED therapies.

Deep vein thrombosis and pulmonary embolism are considered manifestations of the same pathophysiological process and are together referred to as venous thromboembolism (VTE). VTE is a common disorder with an incidence of 1 to 3 in 1000 in the general population. It is estimated that the incidence of VTE is likely to increase as the average life expectancy of the U.S. population increases. Treatment of VTE consists of anticoagulation; the duration of anticoagulation is largely determined by the circumstances surrounding development of the thrombotic event. Vitamin K antagonists, the only oral anticoagulants approved for treatment of VTE in the United States, have several drawbacks and therefore new oral anticoagulants are currently in various stages of development. This review focuses on the risk factors for VTE and the approach to determining the duration of anticoagulation in patients with VTE. Results of clinical trials on the new oral anticoagulants that may soon be licensed for the treatment of VTE are also discussed. [ABSTRACT FROM AUTHOR]

The article discusses quality-related programs of health plans in the U.S. and related legal disputes. It says that in order to improve patient care, health plans use physician tiering, prior authorization, payment policies and disease management which affect patient outcomes. It describes four programs and legal disputes associated with them and challenges like program's impact on patient-provider relationships, administrative burden from the health plans' and physicians' perspective.

Background: Cancer survival is influenced by age, comorbidity, and type of cancer. A population-based study was conducted to compare the interplay between age and mortality for different cancers.Methods: This study analyzed 784,378 cases, comprising 22 of the commonest SEER cancers diagnosed between 1984 and 1993. Competing hazards and proportional hazard analyses for cancer-specific and comorbid death were performed.Results: Median follow-up was up to 159 months, and the median age of diagnosis was 67 years. Cancer-specific and comorbid deaths accumulated most within the first years of diagnosis. With the more biologically aggressive cancers, cancer deaths invariably exceeded comorbid deaths. For the remaining 70% of cancers, comorbidity remained the dominant mode of death. Deaths attributable to both cancer and comorbidity accumulated mostly after the seventh decade of life. Cancer site had a 3-fold greater effect on overall survival than age at diagnosis and a 30-fold effect with cancer-specific survival; age at diagnosis had a 5-fold greater effect on comorbid deaths than site.Conclusions: Both the age of the affected individual and the biology of the particular cancer have major influences on cancer survival and mode of death. Cancer is largely a disease of the elderly. Within affected individuals, fatalities attributable to cancer and comorbidity appeared inter-related, with cancer-specific deaths dominating for more lethal cancers and comorbid deaths dominating for the remaining majority. For these reasons, further improvements in overall survival may be best anticipated from better geriatric and general medical management as much as from better cancer management. [ABSTRACT FROM AUTHOR]

Objective: Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical management (MM) for BTAI. We hypothesized from the results of several previously reported studies, that patients with a minimal aortic injury (BTAI grades 1 and 2) could safely be treated with definitive MM alone., Methods: The Aortic Trauma Foundation international prospective multicenter registry was used to examine the demographics, injury characteristics, management, and outcomes of patients with BTAI. We analyzed a subset of patients for whom MM was initiated as definitive therapy., Results: From November 2016 to April 2020, 432 patients (median age, 41 years; 76% male; median injury severity score, 34) with BTAI (Society for Vascular Surgery grade 1, 23.6%; grade 2, 14.4%; grade 3, 51.2%; grade 4, 10.9%) were evaluated. Of the 432 patients, 245 (57%) had received MM in the initial period and 114 (26.4%) had received MM as the planned definitive therapy (grade 1, 59.6%; grade 2, 23.7%; grade 3, 15.8%; grade 4, 0.9%). The most common mechanism of BTAI was a motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was used for 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) the most common agent used. Treatments were targeted to a goal systolic blood pressure for 83.3%, most often to a target goal systolic blood pressure <120 mm Hg (66.3%). The MM goals based on blood pressure control were attained in 64.0% (73 of 114). Twelve patients (10.5%; grade 1, 1; grade 2, 0; grade 3, 10; grade 4, 1) had required subsequent intervention after MM. Eleven patients (9.6%) had undergone thoracic endovascular aortic repair and one (0.9%) had required open repair for a grade 4 injury. The overall in-hospital mortality for patients selected for definitive MM was 7.9%. No aortic-related deaths had occurred in the patients receiving definitive MM., Conclusions: Approximately one in four patients with BTAI will receive MM as definitive therapy. The variation in the pharmacologic therapies used is considerable. MM for patients with minimal aortic injury (BTAI grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support the use of definitive MM for grade 2 BTAI., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background Underuse of guideline-recommended therapy in peripheral artery disease (PAD) in administrative and procedural databases has been described, but reports on medically managed patients and referral to supervised exercise therapy (SET) in PAD are lacking. We aimed to document the use of PAD guideline-recommended therapy, including SET in patients with PAD symptoms consulting a specialty clinic across 3 countries. Methods and Results The 16-center PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry enrolled 1275 patients with new or an exacerbation of PAD symptoms (2011-2015). We prospectively documented antiplatelet medications, statins, smoking cessation counseling and/or therapy, and referral to SET: "2 quality measures" referred to the use of both statin and antiplatelet medications; "4 quality measures" to receiving all 4 measures. Median odds ratios were calculated to quantify treatment variation across sites. A total of 89% patients were on antiplatelets, 83% on statins, and 23% had been referred to SET. Of 455 current smokers, 342 (72%) patients received smoking cessation therapy/counseling. Overall, 77.2% of patients received "2 quality measures" and 19.7% "4 quality measures." The median odds ratio for 2 quality measures was 2.13 (95% CI, 1.61-3.56; P <0.001) and for 4 quality measures was 5.43 (95% CI, 2.84-17.91; P <0.001). Variability in adherence was not explained by country, except for referral to SET. The odds for SET referral in The Netherlands (70% referral rate) was nearly 100 times greater than in US sites (2% referral rate). Conclusions Not all patients who have undergone a PAD workup at a specialty care facility are treated with evidence-based care, especially so for SET.

Diabetes prevalence is increasing in the United States. As of 2017, 30.3 million people in the United States have diabetes (9.4% of population). Of these, an estimated 7.2 million persons are undiagnosed. Prediabetes, a condition that is associated with peripheral neuropathy and is a precurser to diabetes, affects 83.1 million or 33.9% of adults in the United States. Diabetes is most commonly diagnosed by fasting plasma glucose or by an A1C test. An oral glucose tolerance test can also be used, but its use is primarily restricted to research settings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Abnormal uterine bleeding (AUB) is a common problem that negatively impacts a woman's health-related quality of life and activity. Initial medical treatment includes hormonal and nonhormonal medications. If bleeding persists and no structural abnormalities are present, a repeat trial of medical therapy, a levonorgestrel intrauterine system, or an endometrial ablation can be used dependent on future fertility wishes. The levonorgestrel intrauterine system and endometrial ablation are effective, less invasive, and safe alternatives to a hysterectomy in women with AUB. A hysterectomy is the definitive treatment of AUB irrespective of the suspected cause when alternative treatments fail. Future studies should focus on detection of predictors for treatment outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

It is well known that patients who suffer from peripheral (noncardiac) vascular disease often have coexisting atherosclerotic diseases of the heart. This may leave the patients susceptible to major adverse cardiac events, including death, myocardial infarction, unstable angina, and pulmonary edema, during the perioperative time period, in addition to the many other complications they may sustain as they undergo vascular surgery procedures, regardless of whether the procedure is performed as an open or endovascular modality. As these patients are at particularly high risk, up to 16% in published studies, for postoperative cardiac complications, many proposals and algorithms for perioperative optimization have been suggested and studied in the literature. Moreover, in patients with recent coronary stents, the risk of non-cardiac surgery on adverse cardiac events is incremental in the first 6 months following stent implantation. Just as postoperative management of patients is vital to the outcome of a patient, preoperative assessment and optimization may reduce, and possibly completely alleviate, the risks of major postoperative complications, as well as assist in the decision-making process regarding the appropriate surgical and anesthetic management. This review article addresses several tools and therapies that treating physicians may employ to medically optimize a patient before they undergo noncardiac vascular surgery.

Total hip and knee replacement are two of the most common and successful elective surgeries preformed in the United States each year. Preoperative medical preparation and postoperative rehabilitation are equally important to a successful outcome. Physical deconditioning, tobacco use, obesity and medical co-morbidities can adversely affect outcomes and should be addressed before any elective procedure. Formal postoperative therapy is geared towards the specific surgery and is aimed at returning the patient to independent activity.