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Introduction: This study evaluated the presence of neurologic sequelae among trauma patients after flexion-extension (F/E) radiographs., Methods: Authors of the study conducted a retrospective review of patients (age ≥ 14 years) with a Glasgow Coma Score of 15 who sustained a blunt traumatic injury and received F/E radiographs. Radiographic scans were defined as positive, negative, inconclusive, or incomplete. The neurologic status of each patient was assessed before and after the F/E radiographs, and at discharge and follow-up., Results: Of the 501 patients included in the analysis, 84.6% (n = 424) had negative F/E radiographs, and 3.2% (n = 16) had positive F/E radiographs. Ten percent (n = 51) of patients had incomplete F/E radiographs, and 2.0% (n = 10) were inconclusive due to the inability to rule out a ligamentous injury. Three patients (0.6%) had MRI-confirmed ligamentous injuries, all of which had initial incomplete F/E radiographs due to pain. No patient had a documented neurological deficit before or after the F/E exam. Three patients with an initial negative F/E radiograph returned to the clinic with symptoms of neurologic sequelae. Two of these patients had symptom resolution with no further issues at future follow-up appointments. The third patient was found to have chronic neurologic symptoms after further evaluation., Conclusions: The inclusion of F/E exams in cervical spine clearance protocols did not demonstrate any new long-term iatrogenic neurologic injuries. Consideration should be given to performing MRIs on patients with incomplete F/E radiographs that cannot rule out a ligamentous injury., (Copyright © 2024 Durler, et al.)

Introduction: Overuse injuries such as tendinosis are a common complaint at sports medicine clinics. When conservative management for tendinosis has failed, ultrasound-guided tendon fenestration and injection procedures, such as dry needling, needling tenotomy, autologous whole blood injections, and prolotherapy, can be utilized for treatment. This study examined the effectiveness of these procedures for pain improvement and ability to return to activity for patients with tendinosis., Methods: This study involved a chart review of patients 15 years or older who underwent at least one treatment for tendinosis at a sports medicine clinic between January 1, 2014 and April 17, 2019. Eligible patients had at least one of the following procedures: 1) percutaneous dry needling, 2) percutaneous needle tenotomy, 3) autologous whole blood injection, and/or 4) prolotherapy. A Current Procedural Terminology (CPT) code query was used to screen patient charts for study inclusion., Results: In total, 680 patients' data were reviewed, and 343 patients met inclusion criteria. Patients underwent a total of 598 unique procedures. Dry needling represented most procedures (62.8%, n = 375). Most patients reported diminished pain at follow up (73.0%, n = 268). Prolotherapy had the highest percentage among the follow up patients reporting diminished pain (81.0%, n = 17). Most patients were able to return to activity at follow-up (47.4%, n = 172). A greater proportion of patients with autologous whole blood injection were able to return to activity (60.7%, n = 85)., Conclusions: Most patients with tendinosis who underwent tendon fenestration or injection procedures reported diminished pain at follow-up. Autologous whole blood injection may be more likely to diminish patient pain and allow return to activity than other procedure types. More research is needed across all anatomical sites to compare the generalized effectiveness of these procedures., (© 2023 The University of Kansas Medical Center.)

Introduction: Prehospital behavioral emergency protocols provide guidance on when a medication may be necessary for prehospital behavioral emergency. However, the final decision of which medication to administer to a patient is made independently by paramedics. The authors evaluated circumstances in a prehospital behavioral emergency when paramedics considered chemical restraints, and factors that go into choosing which medications to administer., Methods: A qualitative research design was used involving paramedics from a Midwestern County in the United States, between November 18 and 26, 2019. A total of 149 paramedics were asked to complete a survey consisting of two open-ended questions to measure their clinical decision-making process and factors considered when selecting a medication from a behavioral emergencies protocol. An immersion-crystallization approach was used to analyze the content of the interviews., Results: There was a 53% (n = 79) response rate. Six major themes emerged regarding the paramedics' decisions to use medication for behavioral emergencies: safety of the patients and paramedics, inability to use calming techniques, severity of the behavioral emergency, inability to assess the patient due to presentation, etiology of the behavioral episode, and other factors, such as age, size, and weight of the patient. Six major themes emerged regarding factors considered when choosing medication for behavioral emergency: etiology of the behavioral emergency, patient presentation, the patients' history and age, desired effect and intended outcome of the medication, and other factors., Conclusions: Emergency medical services (EMS) paramedics relied on several factors, such as safety of all parties involved and etiology of the behavioral emergency in deciding when, and which medication to use in a behavioral emergency. The findings could help EMS administrators to develop protocols, such as how paramedics respond and treat patients with behavioral health emergencies., (© 2023 The University of Kansas Medical Center.)

Introduction: Abdominal vascular injuries are associated with significant morbidity and mortality. Treatment options include non-operative management, open repair, and endovascular procedures. This study aimed to characterize patients and detail treatment modalities among those who sustained a traumatic abdominal vascular injury., Methods: A six-year descriptive retrospective study was conducted at a level 1 trauma center and included all adult patients who sustained an abdominal vascular injury. Data abstracted included demographics, admitting characteristics, mechanism of injury, admitting vitals, injury details, diagnostic and treatment information, hospital course, and follow-up data., Results: Fifty-seven patients were admitted with abdominal vascular injuries, however, 14 patients sustained injuries to smaller vascular branches and were excluded. Most vascular injuries involved the iliac artery (27.9%, n = 12), abdominal aorta (25.6%, n = 11), and inferior vena cava (25.6%, n = 11). Twenty-seven percent (n = 12) of patients sustained an injury to more than one vascular structure. Thirty-four percent of patients (n = 15) died before treatment of the abdominal vascular injury. Among the 28 patients (65.1%) treated for their vascular injuries, 46.4% (n = 13) were treated with open surgery, 32.1% (n = 9) were treated non-operatively, and 21.4% (n = 6) with coil embolization. Sixty-four percent of the patients (n = 18) who survived to discharge presented for follow-up care with a mean follow-up period of 3 ± 4.1 months. There were no vascular reinterventions after discharge for patients who followed up with our hospital., Conclusions: Study findings suggested that appropriately selected cases of traumatic vascular injuries may be managed non-operatively and safely, as there were no mortalities, complications, or reinterventions among these patients., (© 2023 The University of Kansas Medical Center.)

Introduction: There have been many efforts to combat the United States opioid crisis that has been occurring for the past two decades, specifically with postpartum patients that often were prescribed opioids. Prior studies described how accounting for usage of inpatient opioids on the day prior to discharge had an impact on how much discharge opioids were prescribed on the day of discharge. These studies provided a guideline to use the inpatient opioid amount from the day before discharge to determine discharge opioid quantity and minimize how much was being prescribed. In July 2018, the American College of Obstetrics and Gynecologists (ACOG) published Committee Opinion 742, guidelines for obstetricians-gynecologists about post-partum pain management. Prescription pain medications (including opioids, if necessary) require a shared decision-making approach between the physician and patient to determine the medication type and quantity. This study aimed to determine if there were differences in prescribing practices based on the specific post-operative day that opioid prescriptions were written, and if there were differences in the prescribing practices for cesarean deliveries following the publication of ACOG Committee Opinion 742., Methods: This retrospective chart review included patients who had a live cesarean birth at one rural Midwest facility anytime between July 1, 2017 and February 28, 2021. This study excluded those with chorioamnionitis and those discharged after more than four days. Opioid amounts were converted to oral morphine milligram equivalents (MME) for comparison, and total MME was calculated for each prescription. Patients were stratified into two groups based on the day that their discharge opioid medication prescriptions were written (i.e., a day prior to discharge or the day of discharge). Patients were also stratified based on date of delivery, before or after the publication of ACOG Committee Opinion 742., Results: Of 411 cesarean patients, 93.9% (n = 386) had opioids prescribed at discharge, 86% (n = 330) of whom received a prescription written on the day of discharge. There was no difference in the quantity of MMEs, doses per day, or dosage from discharge prescriptions between those written on the day of discharge and those written on a prior day. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 (63.9%, n = 263) received discharge prescriptions with fewer average MMEs (159.53 ± 61.64) than those whose deliveries occurred before the publication (36%, n = 148; 187.35 ± 53.42; χ 2 (1, N = 411) = 17.71; p < 0.001), and they were prescribed fewer doses per day., Conclusions: After cesarean sections, the specific post-operative day did not seem to impact the prescribing trends as there were no differences in MMEs, doses per day, or dosage between prescriptions that were written on the day of discharge and before the day of discharge. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 received discharge prescriptions with fewer MMEs, fewer doses per day, and the same dosage than those whose deliveries occurred before the publication, reflecting the overall national trend of decreasing prescription opioids over these years., (© 2022 The University of Kansas Medical Center.)

Introduction: Pregnancy-related mortality in the United States occurs in 32.3 per 100,000 live births. Rural maternal mortality rates were even higher, and these patients were less likely to receive routine care. The purpose of this cross-sectional study was to compare primary and prenatal care and health behaviors among perinatal mothers living in rural and urban Kansas., Methods: Data were collected from 1,971 pregnant women who participated in Phase 8 Pregnancy Risk Assessment Monitoring System (PRAMS) for Kansas between 2016 and 2018. Respondent location (urban or rural based on NIH classification) was abstracted from birth certificates and frequencies of healthcare visits and secondary healthcare variables were compared., Results: Most respondents (75.1%, n = 1,481) resided in an urban area. Most (84.4%, n = 1,664) women were Caucasian, and the largest category (31.1%, n = 613) was 25 to 29 years old. More urban women reported visiting an obstetrician/gynecologist within 12 months before pregnancy than rural women (p < 0.0001). Urban women reported attending pre-pregnancy dental visits (p = 0.019) and teeth cleanings (p = 0.004) more than rural women. Of the 35.7% of respondents (n = 516) who reported receiving pre-pregnancy counseling on folic acid, prenatal vitamins, or multivitamins, 78.9% (n = 407) resided in an urban area., Conclusions: Rural women reported fewer routine primary and prenatal care behaviors compared to their urban counterparts. Efforts are needed to improve access to obstetrician/gynecologist services, especially for women in rural areas., (© 2022 The University of Kansas Medical Center.)

Introduction: Combustible cigarette use is associated with an increased risk of several cardiovascular diseases; however, less is known about associations between these cardiovascular conditions and electronic cigarette use., Methods: This study investigated relationships between electronic and/or combustible cigarette use and diagnoses of cardiovascular diseases using the National Health Interview Survey from 2014, 2016, 2017, and 2018., Results: Compared to non-users, dual users of electronic and combustible cigarettes had increased likelihood of having prior diagnoses of hypertension (OR 1.660, 95% CI = 1.519-1.814), stroke (OR 2.396, 95% CI = 2.011-2.855), diabetes mellitus (OR 1.219, 95% CI = 1.108-1.341), coronary artery disease (OR 2.211, 95% CI = 1.837-2.660), and myocardial infarction (OR 3.839, 95% CI = 3.232-4.560). Exclusive use of electronic cigarettes was associated with an increased likelihood of having hypertension compared to non-users (OR 1.244, 95% CI = 1.048-1.477)., Conclusions: There were no differences in diagnoses of stroke, diabetes mellitus, coronary artery disease, or myocardial infarction among exclusive electronic cigarette users compared to non-users; however, these associations could change as young electronic cigarette users with hypertension age, indicating the need for continued research., (© 2022 The University of Kansas Medical Center.)

Introduction: Patient controlled analgesia (PCA) is a common form of pain management after spine surgeries, in which patients get custom control of their opioid dose. PCA has been demonstrated as a safe form of analgesia; however, use of PCA comes with risks that can be mitigated by opting for alternative pain management. This study aimed to compare the outcomes of patients using PCA to those with an alternative analgesia protocol that does not involve PCA., Methods: A retrospective chart review from January 2017 to July 2018 was conducted. Patients included in this study were those 18 or older who were admitted to a large midwestern tertiary medical center in Wichita, Kansas, and underwent thoracic or lumbar spinal surgery from a single spine surgeon. Data from patient demographics, comorbidities, and type of procedure were collected and compared to control for possible confounding variables. Patients were divided into two groups: patients receiving a PCA pain protocol post-operatively and those receiving a non-PCA protocol. Statistical analyses were performed and all tests with p < 0.05 were considered significant., Results: This study found patients in the PCA protocol had similar outcomes to those in the alternative analgesia protocol. This was true for both primary and secondary outcomes. The primary outcome was patient length of stay after the operation. Secondary outcomes included readmission rates, frequency of naloxone rescue, transfers to higher levels of care, and total opioid consumption., Conclusions: This study supported that a non-PCA protocol for post-operative pain management yields similar outcomes to a PCA protocol in the setting of thoracic and lumbar surgery., (© 2022 The University of Kansas Medical Center.)

Introduction: In 2019, diabetes was the seventh leading cause of death in the United States. The association between diabetes risk and socio-economic factors in the U.S. has been examined primarily at the national level; little is known about this association at the regional level. This study examined and compared the association between diabetes risk and previously established socio-economic factors across four geographic regions (South, Midwest, West, and Northwest)., Methods: This study analyzed the 2014 Behavioral Risk Factor Surveillance System (BRFSS) data stratified by four geographic regions of the U.S. The risk estimates of diabetes associated with previously established socio-economic factors, as well as diabetes prevalence, were compared across four geographic regions., Results: There was marked variation in association between diabetes risk and previously established risk factors across the four geographic regions. In the South, rural residency was associated with increased diabetes risk, whereas in the other geographic regions rural residency had a protective effect. In the South, the diabetes risk for males was 22% higher compared to females, whereas the risk for males was 41% higher than females in the Northeast. Independently, age had the strongest discriminative ability to distinguish between a person with diabetes and a person without diabetes, whereas ethnicity, race, and sex had the weakest discriminative abilities., Conclusions: These findings suggested a higher prevalence of diabetes by race/ethnicity (non-Hispanic Black and Hispanic) and income across all four regions. Rural residency was highest in the South, but protective in other regions. Overall, age and income provided the highest predictive ability for diabetes risk. This study highlighted differences in diabetes prevalence in association between previously established socio-economic variables and diabetes risk across four geographic regions. These findings could help public health professionals and policy makers in understanding the dynamic relationship between diabetes and risk factors at the regional level., (© 2022 The University of Kansas Medical Center.)

Introduction: In 2019, 25.8% of Kansas high school youth reported using any form of tobacco product. Schools can prevent and reduce youth tobacco use by adopting comprehensive tobacco policies, which include all tobacco products, on school grounds and at school-sponsored, off-campus events, for all individuals at all times, and integrate cessation services for students who violate the tobacco policy. The purpose of this study was to determine the prevalence of comprehensive tobacco policies in unified school districts (USD) across Kansas to determine how many schools have adopted such policies., Methods: All 286 USDs in Kansas were eligible to participate in this study including elementary, middle, and high schools. Participating schools were asked to upload their policies to a website developed by the Kansas Department of Health and Environment (KDHE). Frequencies and percentages were computed to identify the type of tobacco products prohibited, the locations where tobacco use is prohibited, who is prohibited from using tobacco, when tobacco is prohibited, and consequences of students' violation of the tobacco policy., Results: Several USD policies met some of these comprehensive recommendations; however, 97.9% (n = 280) did not. In other words, 2.1% of USD policies (n = 6) were comprehensive in Kansas. Most districts (98.3%, n = 281) presented policies prohibiting use of all forms of tobacco for students, but policies often offered more leniency for faculty/staff and visitors. Fewer districts presented policies prohibiting use of all tobacco products for staff/faculty (73.1%, n = 209) and visitors (45.8%, n = 131) of policies., Conclusions: Nearly all USDs in Kansas have an opportunity to strengthen their tobacco policies. Relatively simple edits can be made to prohibit all tobacco products, prohibit use on school grounds and at school-sponsored, off-campus events, ensure these policies apply to everyone, at all times, and integrate cessation resources for students who violate the tobacco policy., (© 2022 The University of Kansas Medical Center.)

Introduction: Modern laboratory techniques cannot differentiate between Clostridium difficile colonization and infection; therefore, testing must be indicated clinically. To reduce hospital-onset of C. difficile infections (HO-CDI), Ascension Via Christi Hospitals (AVCH) in Wichita intervened in three stages by introducing: 1) a C. diflcile testing algorithm; 2) an electronic medical record (EMR)-based decision support system to enforce said algorithm; and 3) phone calls from the infection prevention department to providers to discontinue tests not collected within 24 hours of the order. The goal of this study was to determine if these interventions improved the HO-CDI rate., Methods: At AVCH, the three study periods were compared: baseline with algorithm training only, the EMR intervention, and the EMR intervention with additional phone calls (EMR with phone calls). Data were abstracted from the hospital EMR., Results: A total of 311 charts were reviewed. Adherence to the algorithm increased from 34% at baseline to 52% after the EMR intervention (p = 0.010). During the EMR with phone calls period, more tests were discontinued (87%; n = 39) compared to baseline (54%; n = 15) and EMR (54%; n = 15; p = 0.003). The HO-CDI rate ranged from 8.5 cases per 10,000 patient-days at baseline, to 7.9 during EMR, to 4.0 during EMR with phone calls (p = 0.007)., Conclusions: The EMR and EMR with phone call interventions were associated with a significant decrease in the HO-CDI rate and an increase in provider adherence to the algorithm., (© 2022 The University of Kansas Medical Center.)

Introduction: Tractional retinal detachment remains a leading cause of severe, persistent vision loss in those with diabetic retinopathy. The purpose of this study was to investigate factors in treatment history associated with outcomes of surgical repair for diabetic tractional retinal detachments., Methods: A retrospective, cohort study design was used. Data on 64 eyes that underwent surgical correction for diabetic tractional retinal detachment were analyzed. For eyes that received any treatment within three months of surgery, the entire treatment history was recorded and analyzed. Eyes with no recorded treatment or only remote treatment outside of three months prior to surgery were considered treatment naïve., Results: Of all eyes, 56% (n = 36) had received treatment for proliferative diabetic retinopathy in the three months prior to surgery. Among those treated, 50% (n = 18) of eyes had both laser and bevacizumab treatments and 44% (n = 16) had only bevacizumab injections. Average best corrected visual acuity (BCVA) for all eyes improved from 1.68 LogMAR (20/1,000) pre-operatively to 1.34 (20/400) post-operatively, p = 0.0017. Average BCVA in eyes with pre-operative treatment history improved from 1.73 (20/1,000) pre-operatively to 1.09 (20/250) post-operatively, p = 0.0006. Average BCVA in treatment-naïve eyes was 1.60 (20/800) pre-operatively and 1.66 (20/1,000) post-operatively, p = 0.638. Eyes treated only with intravitreal injections had an improvement in BCVA from 1.81 (20/1,200) pre-operatively to 0.91 (20/160) post-operatively, p = 0.006. There was no difference between tamponade agents when comparing mean change in BCVA, p = 0.944., Conclusions: There was a relationship between intravitreal injection treatment history and a large improvement in BCVA, and a similar association between combined laser and injection treatment history and improvement in BCVA. These relationships, however, were not present when controlling for confounders in multivariate analysis. There were likely other factors in the patient's treatment history such as timing, quantity, and order of treatments that played a role in the bivariate association observed in this study., (© 2022 The University of Kansas Medical Center.)

Introduction: By 2050, more than 580,000 children in the United States will be diagnosed with type 1 diabetes (T1D). Management of T1D requires careful and continuous intervention, and children with T1D experience unique challenges in disease management compared to their adult counterparts. Diabetes camps are designed to help those with T1D learn diabetes management skills while experiencing summer camp. Psychological aspects are not addressed explicitly in diabetes camps located in Kansas. The purpose of this study was to evaluate the psychological state of past campers and camp counselors from one diabetes camp in Kansas., Methods: Campers and counselors, all of whom had T1D, and attended diabetes camp from 2015 to 2019 in Kansas were recruited to complete a survey about diabetes-related stress, diabetes management self-efficacy, and symptoms of depression. A link to the online survey was distributed to previous campers and counselors by email and through Facebook., Results: A total of 24 camp counselors and 10 campers were surveyed, 100% of whom reported having T1D and attending camp at least once. One-third of respondents (n = 8) reported having severe diabetes-related stress, and 100% (n = 34) reported high levels of diabetes management self-efficacy. Most participants reported moderate levels of depression, and 9% (n = 3) reported a past suicide attempt. These results suggested a relatively high prevalence in signs of psychological distress from former campers and camp counselors with T1D., Conclusions: This study suggested that campers and counselors with T1D have high levels of diabetes-related stress, high diabetes management self-efficacy, and many signs of depression., (© 2022 The University of Kansas Medical Center.)

Introduction: Glycemic control is associated with better health outcomes among patients with diabetes. No previous research has examined the relationship between knowledge of one's insulin dose and glycemic control. This study sought to determine if patients who accurately recalled their insulin dose achieved better glycemic control than patients who could not remember their dose., Methods: Interviews were conducted with 106 patients. Data were collected during patients' appointments at two endocrinology clinics in Wichita, Kansas from May 29, 2018 to February 15, 2019. Adequate glycemic control was defined as an HbA1c of less than 7.5%. A multiple logistic regression model was developed to identify factors associated with glycemic control., Results: Of the 109 patients asked to participate, 105 agreed to participate in the study. About half (45%, n = 48) were male. Patients' mean age was 50 years (SD = 17). Seventy-seven percent (n = 81) were overweight (body mass index (BMI) of 25 to 29.9) or obese (BMI >30). Patients who correctly stated their insulin dose had a mean Hemoglobin A1c (HbA1c) of 6.9% (SD = 0.98), whereas those who incorrectly stated their dose had a mean HbA1c of 9.5% (SD = 1.9; p <0.0001)., Conclusions: There was a significant relationship between knowledge of one's insulin dose and adequate glycemic control., (© 2021 The University of Kansas Medical Center.)

Introduction: Open Streets is an event that promotes physical activity among populations by encouraging city residents to walk and bicycle in streets blocked from motor vehicles. Engagement of businesses is a critical component of Open Streets. This study sought to evaluate the Open Streets ICT 2019 event's impact on adjacent businesses., Methods: A 12-item novel survey was developed for this study. Businesses eligible for study participation included retail and non-retail (e.g., non-profits, churches) sites along the Open Streets ICT route in Wichita, Kansas. To understand how Open Streets ICT impacted businesses, the survey used Likert scale questions to prompt respondents to report sales and visitors experiences during the event. Additionally, respondents reported a percent difference in sales compared to a typical Sunday. A phenomenological approach was used to convey the experiences among study participants during Open Streets ICT., Results: A total of 102 surveys were completed, a 42% response rate. Most businesses (56%, n = 56) reported being open during Open Streets ICT. Many businesses (72%) reported having "more" visitors compared to a typical Sunday. More than half reported they experienced new and regular visitors (54%, n = 30) from the event. Most businesses (64%, n = 36) reported a positive financial impact, and (52%, n = 29) having more sales than a typical Sunday., Conclusions: Open Streets ICT increased sales and the number of visitors among businesses. Respondents reported they plan to participate in the 2020 Open Streets ICT, and if Open Streets ICT was offered twice a year. Finally, most participating businesses reported they recommend that other businesses participate in Open Streets ICT., (© 2021 The University of Kansas Medical Center.)

Introduction: This project sought to compare patient-reported outcomes between patients who received intra-operative radiation therapy (IORT) and those who qualified for IORT but received whole-breast external beam radiation therapy (EBRT) following breast-conserving surgery (BCS)., Methods: Three scales from the BREAST-Q Breast Cancer BCT Module Version 2.0 questionnaire were used to collect patient-reported outcomes regarding post-operative physical well-being of the chest, post-operative satisfaction with breast cosmesis, and post-operative adverse effects of radiation., Results: Patients who received EBRT travelled farther on average than patients who received IORT to complete treatment. Respondents who received IORT reported better physical well-being of the chest than those who received EBRT. Regression revealed that the respondent's age was the determining factor in the difference between IORT and EBRT post-operative physical well-being scores, where younger patients report poorer well-being. There was no difference in patient-reported outcomes regarding post-operative satisfaction with breast cosmesis or adverse effects of radiation., Conclusions: Patients who received IORT reported better physical well-being of the chest than patients who received EBRT. There appeared to be a relationship between age and physical well-being of chest. This study suggested that there was no difference in patient-reported outcomes concerning post-operative satisfaction with breast cosmesis or post-operative adverse effects of radiation between patients who received IORT and those who received EBRT., (© 2021 The University of Kansas Medical Center.)

Introduction: Based upon two large randomized international clinical trials (German Dermatologic Cooperative Oncology Group (DeCOG-SLT) and Multicenter Selective Lymphadenectomy Trial II (MSLT-II)) published in 2016 and 2017, respectively, active surveillance has been demonstrated to have equivalent survival outcomes to completion lymphadenectomy (CLND) for a subset of patients who have microscopic lymph node disease. In this study, the changes in national practice patterns were examined regarding the utilization of CLND after positive sentinel lymph node biopsy (SLNB)., Methods: Using the National Cancer Database, CLND utilization was examined in SLN-positive patients diagnosed with melanoma between 2012 and 2016. A hierarchal logistical regression model with hospital-level random intercepts was constructed to examine the factors associated with SLNB followed by observation vs. SLNB with CLND., Results: Of the 148,982 patients identified, 43% (n = 63,358) underwent SLNB and 10.3% (n = 6,551) had a SLNB with microscopic disease. CLND was performed for 57% (n = 2,817) of these patients. Patients were more likely to undergo CLND if they were ≤ 55 years of age (OR, 1.454; p ≤ 0.0001), ages 56 - 65 (OR, 1.127; p = 0.026), Charlson Deyo Score = 0 (OR, 2.088; p = 0.043), or were diagnosed with melanoma in 2012 (OR, 2.259, p ≤ 0.0001)., Conclusions: The utilization of CLND among patients with microscopic nodal melanoma was significantly lower in 2016 compared to 2012. Younger age, lack of comorbidities, and primary tumor location on the trunk or head/neck were associated with higher utilization of CLND., (© 2021 The University of Kansas Medical Center.)

Introduction: The primary purpose of this study was to evaluate the association between workplace stress and productivity among employees from worksites participating in a WorkWell KS Well-Being workshop and assess any differences by sex and race., Methods: A multi-site, cross-sectional study was conducted to survey employees across four worksites participating in a WorkWell KS Well Being workshop to assess levels of stress and productivity. Stress was measured by the Perceived Stress Scale (PSS) and productivity was measured by the Health and Work Questionnaire (HWQ). Pearson correlations were conducted to measure the association between stress and productivity scores. T-tests evaluated differences in scores by sex and race., Results: Of the 186 participants who completed the survey, most reported being white (94%), female (85%), married (80%), and having a college degree (74%). A significant inverse relationship was observed between the scores for PSS and HWQ, r = -0.35, p < 0.001; as stress increased, productivity appeared to decrease. Another notable inverse relationship was PSS with Work Satisfaction subscale, r =-0.61, p < 0.001. One difference was observed by sex; males scored significantly higher on the HWQ Supervisor Relations subscale compared with females, 8.4 (SD 2.1) vs. 6.9 (SD 2.7), respectively, p = 0.005., Conclusions: Scores from PSS and the HWQ appeared to be inversely correlated; higher stress scores were associated significantly with lower productivity scores. This negative association was observed for all HWQ subscales, but was especially strong for work satisfaction. This study also suggested that males may have better supervisor relations compared with females, although no differences between sexes were observed by perceived levels of stress., (© 2021 The University of Kansas Medical Center.)

Introduction: Kansas has seen a steady increase in the rate of firearm deaths and injuries. Little is known surrounding the demographic and geospatial factors of these firearm-related traumas. The purpose of this study was to describe the overall incidence of firearm-related traumas, identify high injury locations, and examine any racial/ethnic disparities that may exist., Methods: A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017., Results: Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino. Hispanic/Latino patients were the youngest (25.8 ± 8.8 years) and Caucasians were the oldest (34.3 ± 14.1 years, p = 0.002). Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU; p = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7 days, p = 0.031, respectively). African American patients (96.0%) experienced more assaults, while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, p = 0.001). More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest percentage of shotgun/rifle related injuries (16.1%, p = 0.012). Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214. Geographical maps indicated that GSWs occur in neighborhoods with low-income and high minority residents and in the downtown and nightclub areas of the city., Conclusions: Most GSW victims were older Caucasian males. Racial differences were noted and injury locations concentrated in certain locations., (© 2021 The University of Kansas Medical Center.)

Introduction: Opioid overdose caused 47,600 deaths in 2017 in the United States. Emergency departments (EDs) are one source of opioids that could be abused or diverted for non-medical use. Bills to reduce opioid use in EDs have been passed in multiple states; however, Kansas does not have a bill regulating opioid administration. This study sought to identify characteristics that influence opioid administration and prescription at EDs in Wichita, Kansas., Methods: This was a retrospective chart review analyzing patient encounters from EDs of three hospitals in Wichita, Kansas during May 2018. Information collected from charts included demographic and insurance information, as well as pain evaluation, diagnosis, disposition, provider education, and provider documentation of efforts to limit opioid abuse., Results: Of the 1,444 encounters included in the analysis, providers administered opioids in the ED during 17.4% of visits and prescribed opioids for outpatient treatment for 10.6% of ED patient encounters. Subjective pain rating and provider credentials were associated significantly with opioid prescription., Conclusion: The prevalence of opioid administration and prescription in participating emergency departments is roughly equivalent to current best-practice data from hospitals utilizing strong opioid-reduction protocols., (© 2021 The University of Kansas Medical Center.)

Introduction: Traumatic injuries are preventable and understanding determinants of injury, such as socio-economic and environmental factors, is vital. This study evaluated traumatic injuries and identified areas of high trauma incidence., Methods: A retrospective review was conducted of all patients 14 years or older who were admitted with a traumatic injury to a Level I trauma center between 2016 and 2017. Descriptive analyses were presented and maps of high injury areas were generated., Results: The most frequent mechanisms of injury were falls (58.3%), motor vehicle crashes (22.3%), and motorcycle crashes (5.7%). Fall patients were more likely to be female (59.6%) and were the oldest age group (72.1 ± 17.2) compared to motor vehicle and motorcycle crash patients. Severe head (22.1%, p = 0.007) and extremity (35.7%, p = 0.001) injuries were most frequent among fall patients, however, more motorcycle crash patients required mechanical ventilation (16.1%, p < 0.001) and experienced the longest intensive care unit length of stay (5.3 ± 6.8 days, p < 0.001) and mechanical ventilation days (6.6 ± 8.5, p < 0.036). Motorcycle crash patients also had the greatest number of deaths (7.5%, p < 0.001). The generated maps of all traumas suggested that most injuries occur near our hospital and are located in several of the most population-dense zip codes., Conclusion: Patient demographics, injury severity, and hospital outcomes varied by mechanisms of injury. Traumatic injuries occurred near our hospital and were located in several of the most populationdense zip codes. Injury prevention efforts should target high incident areas., (© 2021 The University of Kansas Medical Center.)

Introduction: The impact of dyspepsia guidelines on clinical practice may be poor. Provider adherence with dyspepsia guidelines was examined to determine their impact on clinical practice., Methods: Provider adherence with the 2005 American College of Gastroenterology Guidelines for the Management of Dyspepsia and the 2017 American College of Gastroenterology and Canadian Association of Gastroenterology joint Dyspepsia Management Guidelines was assessed on a national level using data from the National Ambulatory Medical Care Survey (NAMCS). Patient visit data, including reason for visit of dyspepsia, diagnosis of dyspepsia, or diagnosis of H. pylori infection from NAMCS years 2012 through 2015, were used. Provider adherence with dyspepsia management guidelines was determined based upon provision of at least one recommended test or treatment for dyspepsia., Results: Providers appeared to adhere to the 2005 ACG guidelines for 49.7% of patient visits. Providers appeared to adhere to the 2017 ACG/CAG guidelines for 51.0% of patient visits., Conclusion: Provider adherence with the 2005 ACG and the 2017 ACG/CAG Dyspepsia Management Guidelines was determined to be low in this study, highlighting the need to increase evidence-based medical treatment and efficient resource use for dyspepsia., (© 2020 The University of Kansas Medical Center.)

Introduction: Diabetes mellitus (DM) disproportionately affects people with low socioeconomic status (SES). Student-run free clinics (SRFC) aim to care for low SES populations and experience high clinician turnover. Flow sheets have been used to improve care for those with diabetes, yet no research has assessed the use of such a flow sheet in a SRFC. The aim of this project was to determine if use of a flow sheet improved care for people with DM in an SRFC., Methods: Charts from all patients receiving care for DM at one SRFC in the year before (n = 53) and after (n = 56) implementation of the flow sheet were reviewed. Pre- and post-group comparisons and post subgroup comparisons were made for glycosylated-hemoglobin (HgbA1c), microalbumin, and foot and eye exams., Results: During a one-year period, a larger proportion of patients who received care post flow sheet introduction received at least two HgbA1c tests (53%), a microalbumin test (46%), and a foot-exam (46%) compared to those receiving care before the flow sheet (28%, 2%, and 25%, respectively). There was no difference in proportions of patients undergoing eye exams. In post subgroup analysis, flow sheets were used for 50% of patients, and patients who received care with the flow sheet were more likely to receive at least two HgbA1c tests and a foot exam per year., Conclusion: Flow sheets may improve the process of care for patients with diabetes in a SRFC, but the effect must be studied further. Regardless, a systematic integration of the flow sheet is being implemented in the SRFC evaluated in this study., (© 2020 The University of Kansas Medical Center.)

Introduction: The purpose of this study was to identify additional injuries commonly seen with proximal humerus fractures experienced by patients 65 years or older and to evaluate discrepancies in the management of these patients with regard to provider type., Methods: A retrospective review was conducted of all patients 65 years or older who sustained a proximal humerus fracture. Patient data collected included demographics, injury details, hospital course, and discharge destination., Results: Patients with a concomitant fracture (45.5%, n = 65) had a slightly higher Injury Severity Score (ISS; 8.3 ± 3.0 vs. 6.4 ± 3.0, p < 0.001) and experienced one additional death than those with an isolated fracture (54.5%, n = 78). Slightly more patients were managed by a trauma provider (51.7%, n = 74) than by a non-trauma provider (48.3%, n = 69). Those managed by a trauma provider sustained the most pelvic fractures (12.2% vs. 2.9%, p = 0.038), were more likely to be injured in a motor vehicle collision (8.1% vs. 0%, p = 0.005), had a higher ISS (8.0 ± 3.3 vs. 6.4 ± 2.8, p = 0.003), and had more imaging performed than those treated by a non-trauma provider. There was, however, no difference in operative rates, concomitant injuries, length of stay, or discharge disposition regarding provider type., Conclusion: It is important to recognize proximal humerus fractures as a sign of fragility and to optimize hospital management of these patients., (© 2020 The University of Kansas Medical Center.)

Introduction: The five-year survival rate for patients with glioblastoma (GBM) is low at approximately 4.7%. Radiotherapy plus concomitant and adjuvant temozolomide (TMZ) remains the standard of care. The optimal duration of therapy with TMZ is unknown. This study sought to evaluate the survival benefit of two years of treatment., Methods: This was a retrospective chart review of all patients diagnosed with GBM and treated with TMZ for up to two years between January 1, 2002 and December 31, 2011. The Kaplan-Meier method with log-rank test was used to estimate the progression-free survival (PFS) and the overall survival (OS). The results were compared to historical controls and data from previous clinical trials of patients treated up to one year., Results: Data from 56 patients with confirmed GBM were evaluated. The OS probability was 54% (SE = 0.068) at one year, 28.3% (SE = 0.064) at two years, 17.8% (SE = 0.059) at three years, and 4% (SE = 0.041) at five years. Seven patients (12.5%) were treated with TMZ for two years. Their median time-to-progression was 28 months (95% CI = 5.0 - 28.0), and they had an increased survival probability at three years compared to other patients (log-rank test χ 2 (1, N = 56) = 19.2, p < 0.0001)., Conclusions: There may be an advantage for a longer duration of TMZ therapy among patients with GBM, but the sample size was too small for generalization. A multicenter prospective study is needed to identify optimal duration of TMZ therapy.

Introduction: Traditional evaluation of meningitis includes cerebrospinal fluid (CSF) culture and gram stain to pinpoint specific causal organisms. The BioFire ® FilmArray ® Meningitis/Encephalitis (ME) Panel has been implemented as a more timely evaluation method. This study sought to assess if the BioFire ® ME Panel was associated with a decreased length of stay or decreased antimicrobial duration when used in the diagnosis of meningitis or encephalitis., Methods: A case, historical-control, chart review was performed on patients admitted to a regional medical center with CSF pleocytosis during Cohort 1 (the year prior to BioFire ® ME Panel implementation) and Cohort 2 (the year after BioFire ® ME Panel implementation). Length of hospital stay, duration of antimicrobials, and BioFire ® ME Panel result were gathered and analyzed., Results: Average length of stay for both cohorts was about four hospital days. Approximately three-fourths of all patients received antibiotic/antiviral treatment with an average of three days duration. No significant differences were observed between groups. The mean (median) duration of antimicrobials in the year prior to and after the BioFire ® ME Panel implementation was 3.6 (3) and 3.1 (2) days, respectively (p = 0.835). The mean (median) length of stay in the year prior to and after the BioFire ® ME Panel implementation was 5.8 (4) and 5.4 (4) days, respectively (p = 0.941). Among the patients admitted after the implementation of the BioFire ® ME Panel, 4.3 % (n = 2) had a positive bacterial result, 38.3% (n = 18) had a positive viral result, and 57.4% (n = 27) had a negative result. Of the 27 negative results, 77.8% (n = 21) were treated with antimicrobial medication., Conclusions: This study suggested there is no difference between length of stay or antimicrobial duration in presumed meningitis cases assessed with traditional methods as compared to the BioFire ® ME Panel.

Introduction: Recent studies have provided guidelines on the use of head computed tomography (CT) scans in pediatric trauma patients. The purpose of this study was to identify the prevalence of these guidelines among concussed pediatric patients., Methods: A retrospective review was conducted of patients four years or younger with a concussion from blunt trauma. Demographics, head injury characteristics, clinical indicators for head CT scan (severe mechanism, physical exam findings of basilar skull fracture, non-frontal scalp hematoma, Glasgow Coma Scale score, loss of consciousness, neurologic deficit, altered mental status, vomiting, headache, amnesia, irritability, behavioral changes, seizures, lethargy), CT results, and hospital course were collected., Results: One-hundred thirty-three patients (78.2%) received a head CT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. All patients with skull fractures and/or bleeds had at least one clinical indicator present on arrival. Clinical indicators that were observed more commonly in patients with positive CT findings than in those with negative CT findings included severe mechanism (100% vs. 54.8%, respectively, p = 0.020) and signs of a basilar skull fracture (28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alone was found to be sensitive, but not specific, whereas signs of a basilar skull fracture, headache, behavioral changes, and vomiting were specific, but not sensitive. No neurosurgical procedures were necessary, and there were no deaths., Conclusion: Clinical indicators were present in patients with positive and negative CT findings. However, severe mechanism of injury and signs of basilar skull fracture were more common for patients with positive CT findings.

Introduction: This study compared outcomes between patients injured at a motorbike track, which requires riders to follow safety equipment guidelines, and those involved in recreational riding where safety equipment usage is voluntary., Methods: A retrospective review was conducted of all patients presenting with motorbike-related injuries at an American College of Surgeons verified level-I trauma center between January 1, 2009 and December 31, 2013. Data collected included demographics, injury details, safety equipment use, hospitalization details, and discharge disposition. Comparisons were made regarding protective equipment usage., Results: Among the 115 patients admitted, more than half (54.8%, n = 63) were injured on a motorbike track, and 45.2% (n = 52) were injured in a recreational setting. The majority of patients were male (93.9%), Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmet usage was higher among track riders (95.2%, n = 60) than recreational riders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity and outcomes between those who wore protective equipment and those who did not were not significant., Conclusion: Even though track riders wore protective equipment more than recreational riders, there was no difference between the groups regarding injury severity or hospital outcomes. These results suggested that motocross riders should not rely on protective equipment as the only measure of injury prevention.

Introduction: Direct primary care (DPC), a fee for membership type of practice, is an evolving innovative primary care delivery model. Little is known about current membership fees, insurance billing status, physician training, and patient panel size in DPC practices. This study aimed to obtain current data for these variables, as well as additional demographic and financial indicators, and relate the findings to the Healthy People 2020 goals. It was predicted that DPC practices would (1) submit fewer claims to insurance, (2) have decreased membership fees, (3) be primarily family medicine trained, and (4) have increased the projected patient panel size since 2005., Methods: An electronic survey was sent to DPC practices (n = 65) requesting location, membership fees, projected patient panel size, insurance billing status, training, and other demographic and financial indicators. Data were aggregated, reported anonymously, and compared to two prior characterizations of DPC practices done in 2005., Results: Thirty-eight of 65 (59%) practices responded to the 2015 survey. The majority of respondents (84%) reported using an EMR, offering physician email access (82%), 24-hour access (76%), same day appointments (92%), and wholesale labs (74%). Few respondents offered inpatient care (16%), obstetrics (3%), or financial/insurance consultant services. Eighty-eight percent (88%) of practices reported annual individual adult membership rates between $500 and $1,499, decreased from 2005 where 81% reported greater than a $1,500 annual fee. The proportion of practices who submit bills to insurance decreased from 75% in 2005 to 11% in 2015. Fifty-six percent (56%) of practices reported projected patient panel size to be greater than 600, increased from 40% in 2005. Family medicine physicians represented 87% of respondents, markedly different from 2005 when 62 - 77% of DPC respondents were general internal medicine physicians., Conclusions: Most DPC practices no longer submit to insurance and are family medicine trained. Compared with the previous sampling, DPC practices report decreased membership fees and increased projected panel size. These trends may signify the DPC movement's growth in application and scope.