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Introduction Molecular testing has helped clinicians and cytopathologists to further categorize indeterminate thyroid fine needle aspiration (FNA) specimens. The purpose of the present study was to evaluate the accuracy of commercially available molecular tests, review their effects on patient treatment, and correlate the molecular alterations with the histologic findings. Materials and methods A pathology laboratory information system search identified thyroid FNAs performed at our institution between January 1, 2015 and June 30, 2020. The results of surgical follow-up and ancillary molecular testing were collected. We evaluated the accuracy of these tests and whether they could reduce the number of surgeries performed. Results Our laboratory information system search identified 510 cases reported as atypia of undetermined significance, 94 as suspicious for follicular neoplasm, and 44 as suspicious for follicular neoplasm, Hurthle cell type. Of the specimens, 343 had no ancillary molecular testing, 146 were sent for ThyGenX/ThyraMIR, and 136 were sent for ThyroSeq. Of the patients without molecular testing, 50.4% had undergone follow-up surgery compared with 30.8% after ThyGenX/ThyraMIR and 38.2% after ThyroSeq testing, resulting in 38.9% and 24.2% fewer surgeries and an odds ratio of 0.04 (95% confidence interval, 0.00-0.33) and 0.14 (95% confidence interval, 0.01-0.95), respectively. For ThyGenX/ThyraMIR testing, the risk of malignancy for high and moderate to high risk alterations was 80%, 28.6% for moderate and low to moderate risk alterations, and 23.1% for low risk alterations. For ThyroSeq, the risk of malignancy was 87.5% for high risk alterations, 36.8% for intermediate to high risk alterations, 27.3% for intermediate risk alterations, and 0% for low risk alterations. The areas under the curve for ThyGenX/ThyraMIR and ThyroSeq testing were 0.65 and 0.85, respectively. Conclusions These findings suggest that, at our institution, both ThygenX/ThyraMIR and ThyroSeq can be used to effectively stratify cytology specimens based on the risk of malignancy and reduce the number of surgeries performed at our institution.

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p

Background The Bethesda System for Reporting Thyroid Cytopathology contains an atypia of undetermined significance (AUS) category with heterogeneous and distinct inclusion criteria. The purpose of this study was to investigate differences in malignancy rates and molecular alterations based on the presence of different criteria. Methods A laboratory information search was conducted to identify thyroid fine-needle aspiration specimens signed out as AUS. The cases were reclassified as architectural atypia (3A), cytologic atypia (3C), both architectural and cytologic atypia (3B), or Hurthle cell aspirate (3H). Surgical follow-up and concurrent molecular test results, if available, were collected. Results Five hundred ten specimens, including 258 reclassified as 3A, 40 reclassified as 3B, 119 reclassified as 3C, and 86 reclassified as 3H, were identified. The risks of malignancy for the subcategories were 13.4%, 26.3%, 44.1%, and 13.8%, respectively. Additionally, BRAF V600E mutations were more prevalent in specimens with cytologic atypia (3B/3C), whereas low-risk alterations, including KRAS, PTEN, and PAX8-PPARy2, were more prevalent in those with architectural atypia (3A). Conclusions Subdividing AUS specimens on the basis of the type of atypia can yield categories associated with distinct molecular alterations and risks of malignancy.

Purpose Little is known about prevalence and treatment of OUD among youth engaged in primary care (PC). Medications are the recommended treatment of opioid use disorder (OUD) for adolescents and young adults (youth). This study describes the prevalence of OUD, the prevalence of medication treatment for OUD, and patient characteristics associated with OUD treatment among youth engaged in PC. Methods This cross-sectional study includes youth aged 16–25 years engaged in PC. Eligible patients had ≥ 1 PC visit during fiscal years (FY) 2014–2016 in one of 6 health systems across 6 states. Data from electronic health records and insurance claims were used to identify OUD diagnoses, office-based OUD medication treatment, and patient demographic and clinical characteristics in the FY of the first PC visit during the study period. Descriptive analyses were conducted in all youth, and stratified by age (16–17, 18–21, 22–25 years). Results Among 303,262 eligible youth, 2131 (0.7%) had a documented OUD diagnosis. The prevalence of OUD increased by ascending age groups. About half of youth with OUD had documented depression or anxiety and one third had co-occurring substance use disorders. Receipt of medication for OUD was lowest among youth 16–17 years old (14%) and highest among those aged 22–25 (39%). Conclusions In this study of youth engaged in 6 health systems across 6 states, there was low receipt of medication treatment, and high prevalence of other substance use disorders and mental health disorders. These findings indicate an urgent need to increase medication treatment for OUD and to integrate treatment for other substance use and mental health disorders.

BACKGROUND: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN: Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014–2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06389-7.

Background Emergency general surgery (EGS) has high rates of morbidity, mortality, and readmission. Therefore, it might be expected that an EGS service fields many consultations for postoperative patients. However, with the known overutilization of emergency department visits for nonurgent conditions, we hypothesized most postoperative consults received by an EGS service would be nonurgent and could be appropriately managed as an outpatient. Methods We reviewed all EGS consults at a single urban safety net hospital over a 12-month period, screening for patients who had undergone surgery in the previous 12 mo. This included consultations from the emergency room and inpatient setting. Demographics, admission status, procedures performed, and other details were abstracted from the chart and Vizient reports. Consultation questions were categorized and then reviewed by an expert panel to determine if conditions could have been managed as an outpatient. Results The EGS service received a total of 1112 consults, with 99 (9%) for a postoperative condition. Overall, 85% of postoperative consults were admitted after consultation, 19% underwent surgery and 21% underwent a procedure with gastroenterology or interventional radiology. Expert review classified slightly over one-third (36%) of consults as nonurgent. Conclusions Most postoperative consults seen at our urban safety net hospital represent true morbidity that required admission, intervention, or surgery. Despite this high acuity, one-third of postoperative consults could have been managed as an outpatient. Efforts to improve discharge instructions and set patient expectations could limit unnecessary postoperative emergency department visits.

Background Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here. Methods PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16–90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims (“electronic health records,” [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization. Discussion The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings. Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1

Objectives Transgender people-those whose gender identity differs from their sex assigned at birth-are at risk for health disparities resulting from stressors such as discrimination and violence. Transgender people report more drug use than cisgender people; however, it is unclear whether they have higher likelihood of drug use disorders. We examined whether transgender patients have increased likelihood of documented drug use disorders relative to cisgender patients in the national Veterans Health Administration (VA). Methods Electronic health record data were extracted for VA outpatients from 10/1/09 to 7/31/17. Transgender status and past-year documentation of drug use disorders (any, opioid, amphetamine, cocaine, cannabis, sedative, hallucinogen) were measured using diagnostic codes. Logistic regression models estimated odds ratios for drug use disorders among transgender compared to cisgender patients, adjusted for age, race/ethnicity and year. Effect modification by presence of ≥1 mental health condition was tested using multiplicative interaction. Results Among 8,872,793 patients, 8619 (0.1%) were transgender. Transgender patients were more likely than cisgender patients to have any drug use disorder (Adjusted Odds Ratio [aOR] 1.67, 95% confidence interval [CI] 1.53-1.83), amphetamine (aOR 2.22, 95% CI 1.82-2.70), cocaine (aOR 1.59, 95% CI 1.29-1.95), and cannabis (aOR 1.82, 95% CI 1.62-2.05) use disorders. There was no significant interaction by presence of ≥1 mental health condition. Conclusions Transgender VA patients may have higher likelihood of certain drug use disorders than cisgender VA patients, particularly amphetamine use disorder. Future research should explore mechanisms underlying disparities and potential barriers to accessing treatment and harm reduction services faced by transgender people.

We review the underappreciated problem of elder abuse with a focus on what trauma surgeons need to know. Because of its prevalence, it is important that clinicians understand types of elder abuse, risk factors in patient and perpetrator, prevention strategies, and the appropriate referral and treatment of potential victims of elder abuse. Elder abuse affects at least 10% of older individuals in the USA. Despite much effort to address the problem via legal and societal approaches, data to support particular programs are poor. And even with extensive efforts, the utility of established prevention strategies or existing screening tools to identify victims of elder abuse in the acute care setting has yet to be established. Elder abuse is a public health problem. As a society, we have only begun to define the extent of the problem. Healthcare systems have failed to effectively prevent or to accurately screen for, diagnose, and report elder abuse. The next steps include broader public awareness, educational initiatives, improved screening tools, and effective intervention strategies. In the meantime, we as trauma surgeons can be more diligent in reporting.

Social interactions are largely dependent on the interpretation of information conveyed through facial expressions. Although facial reanimation seeks restoration of the facial expression of emotion, outcome measures have not addressed this directly. This study evaluates the use of a machine learning technology to directly measure facial expression before and after facial reanimation surgery. Fifteen study subjects with facial palsy were evaluated both before and after undergoing cross-facial nerve grafting and free gracilis muscle transfer. Eight healthy volunteers were assessed for control comparison. Video footage of subjects with their face in repose and with a posed, closed-lip smile was obtained. The video data were then analyzed using the Noldus FaceReader software application to measure the relative proportions of seven cardinal facial expressions detected within each clip. The facial expression recognition application detected a far greater happy signal in postoperative (42 percent) versus preoperative (13 percent) smile videos (p < 0.0001), compared to 53 percent in videos of control faces smiling. This increase in postoperative happy signal was achieved in exchange for a reduction in the sad signal (15 percent to 9 percent; p = 0.092) and the neutral signal (57 percent to 37 percent; p = 0.0012). For video clips of patients in repose, no significant difference in happy emotion was detected between preoperative (3.1 percent) and postoperative (1.4 percent) states (p = 0.5). This study provides the first proof of concept for the use of a machine learning software application to objectively quantify facial expression before and after surgical reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.

Background: Coronavirus disease 2019 (COVID-19) has a substantial mortality risk with increased rates in the elderly. We hypothesized that age is not sufficient, and that frailty measured by preadmission Palliative Performance Scale would be a predictor of outcomes. Improved ability to identify high-risk patients will improve clinicians’ ability to provide appropriate palliative care, including engaging in shared decision-making about life-sustaining therapies. Aim: To evaluate whether preadmission Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19. Design: Retrospective observational cohort study of patients admitted with COVID-19. Palliative Performance Scale was calculated from the chart. Using logistic regression, Palliative Performance Scale was assessed as a predictor of mortality controlling for demographics, comorbidities, palliative care measures and socioeconomic status. Setting/participants: Patients older than 18 years of age admitted with COVID-19 to a single urban public hospital in New Jersey, USA. Results: Of 443 admitted patients, we determined the Palliative Performance Scale score for 374. Overall mortality was 31% and 81% in intubated patients. In all, 36% (134) of patients had a low Palliative Performance Scale score. Compared with patients with a high score, patients with a low score were more likely to die, have do not intubate orders and be discharged to a facility. Palliative Performance Scale independently predicts mortality (odds ratio 2.89; 95% confidence interval 1.42–5.85). Conclusions: Preadmission Palliative Performance Scale independently predicts mortality in patients hospitalized with COVID-19. Improved predictors of mortality can help clinicians caring for patients with COVID-19 to discuss prognosis and provide appropriate palliative care including decisions about life-sustaining therapy.

Background Identifying individuals at highest risk maximizes efficacy of prevention programs in decreasing recidivist gunshot wound (GSW) injury. Characteristics of GSW recidivists may identify this population. Hospital-based violence intervention programs (HVIPs) are one effective strategy; however, programs are expensive, therefore, when possible, epidemiologic data should guide inclusion criteria. Methods Seventeen years of all GSW patients presenting to an urban Level I trauma center were reviewed. Countywide murders were reviewed from the same timeframe. Recidivists were any patient presenting twice, either to the hospital or once to the hospital and subsequently dying by firearm. Demographics and characteristics of future recidivists were compared with nonfuture recidivists. Results There were 9,699 unique intentional, GSW cases reviewed and 1,426 died, leaving 8,273 at risk of recidivism. Five hundred fourteen (6.2%) became recidivists. Most recidivists were African-American men and were younger at first GSW. Median time between incidents was 2.5 years, with a range of 0 days to 16 years. Nearly half were treated and released from the emergency department at their first episode of GSW. For recidivists who died, 128 died at the second incident, 29 at later incidents. Mortality from a second incident of firearm injury is 10% higher than first injuries, second hospitalizations are US $5,000 more expensive, and loss of life has a societal cost of US $167 billion in this community alone. Conclusion The most appropriate population for inclusion in HVIPs at our hospital are young black men. The HVIP services are needed in the emergency department to address those treated and released at first GSW. Recidivists have higher mortality, and hospitalizations are significantly more expensive at the second injury. The investment in prevention is justified and may lead to a decrease in recidivism. Level of evidence Therapeutic/Care Management level III.

Background Sepsis in older children is often associated with the presence of developmental abnormalities and cerebral palsy. While relatively uncommon, surgical abdomen in these patients is associated with a high rate of mortality. Few reports have been described of sepsis caused by isolated cecal necrosis. Case Report We report a 13-year-old child with cerebral palsy and global developmental delay who presented to the emergency department with acute worsening abdominal distention that the mother attributed to chronic constipation. Clinical evaluation revealed that she was in severe septic shock and needed immediate stabilization after which she underwent an exploratory laparotomy. Operative findings revealed cecal necrosis that necessitated an ileocecectomy. Why Should an Emergency Physician be Aware of This? Children with intellectual disabilities presenting with sepsis to the emergency department can be particularly challenging given the communication barriers and the time-sensitive nature of the condition. When evaluating these patients, a thorough history and examination are often the only tools that assist in the early identification of the infectious source, leading to improved clinical outcomes.© 2019 Elsevier Inc.

Evidence supports index cholecystectomy as the quality of care for patients admitted with acute cholecystitis. We sought to examine the role of hospital safety-net status on whether patients received appropriate index procedures for cholecystitis. The National Inpatient Sample was queried for patients with acute cholecystitis. Proportion of Medicaid and uninsured discharges were used to define safety-net hospitals (SNHs). Multivariate logistic regression was used to calculate associations between the frequency of index cholecystectomy and prolonged length of stay (LOS), and the effect of SNH designation. SNHs and non-SNHs had similar rates of index cholecystectomy in all geographic regions, except in the northeast, where the likelihood of having an index cholecystectomy was lower at SNHs. Patients at SNHs had longer LOS for acute cholecystitis, regardless of index or delayed cholecystectomy. When controlling for insurance status, patients at SNHs had longer LOS than those at non-SNHs. There was also increased LOS in SNHs in the Midwest, in urban hospitals, and in large hospitals. Our data showed no difference in the frequency of index cholecystectomy overall between SNHs and non-SNHs, except in the northeast. The variability and increased LOS at SNHs highlight potential opportunities to improve quality and decrease cost of care at our most vulnerable hospitals.

Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort.We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC.In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p 0.001). Time to first re-laparotomy was highly significant (p 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p 0.001) for 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002).Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL.2B.

BackgroundDamage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.MethodsWe reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.ResultsAmong 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).ConclusionNontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.Level of evidenceTherapeutic study, level IV.

BACKGROUND AND AIMS Alcohol screening, brief intervention (BI) and referral to treatment is often considered stepped care, such that BI with referral links patients to treatment. A meta-analysis of randomized trials found no evidence that BI increases treatment for alcohol use disorder (AUD). This study aimed to determine whether BI is associated with receipt of treatment for AUD among patients receiving BI as part of routine care. DESIGN Regression analysis. SETTING US Veterans Health Administration (VA), in which BI is supported by performance measurement and electronic clinical reminders. PARTICIPANTS VA outpatients with positive Alcohol Use Disorders Identification Test Consumption screens (≥ 5) (n = 830,825) documented nationally from 1 October 2009 to 30 May 2013. MEASUREMENTS Regression models estimated the prevalence of receiving VA specialty addictions treatment within 0-365 days for patients with documented BI (advice to reduce/abstain within 0-14 days) compared to those without. Models clustered on patient and adjusted for demographics and mental health and substance use conditions were fit among all patients and stratified across documented past-year AUD diagnosis. Multiple secondary analyses assessed robustness of findings, including assessing repeated BI as a predictor. FINDINGS Among 830,825 VA outpatients with unhealthy alcohol use (1,172,606 positive screens), documented BI was associated with lower likelihood of receiving VA specialty addictions treatment [adjusted incidence rate ratio (aIRR) = 0.84, 95% confidence interval (CI) = 0.83-0.84]. Associations were similar for those with and without AUD (aIRR = 0.83, 95% CI = 0.82-0.84 and aIRR = 0.86, 95% CI = 0.83-0.88, respectively) and in most secondary analyses. However, among patients without AUD, documentation of more than one BI was associated with greater likelihood of treatment relative to no BI (aIRR = 1.75, 95% CI = 1.68-1.83). CONCLUSIONS In a national sample of US Veterans Health Administration patients with unhealthy alcohol use, documented brief intervention for alcohol use was associated with lower likelihood of receiving specialty addictions treatment regardless of alcohol use disorder diagnosis.

Background Trauma is a major cause of death and disability in all ages. Previous reviews have suggested that National Institutes of Health (NIH) funding for trauma is not commensurate with its burden of disease, but a detailed analysis has been lacking. We postulated that NIH spending on trauma research was lower than previously thought and was distributed widely, preventing a comprehensive research strategy that could decrease trauma morbidity and mortality. Methods The NIH Research Portfolio Online Reporting Tool was initially screened using a search of over 20 terms including "trauma," "injury," "shock," "MVC," and excluding clearly unrelated conditions, for example, "cancer." The details of all grants that screened positive underwent manual review to identify true trauma-related grants. An expert panel was used to adjudicate any ambiguity. Results In FY2016, NIH awarded 50,137 grants, of which 6,401 (13%) were captured by our initial screen. Following review, 1,888 (28%) were identified as trauma-related; 3.7% of all NIH grants. These grants (US $720 million) represent only 2.9% of the NIH extramural budget. In addition, the grants were funded and administered by 24 of the institutes and centers across the NIH ranging from 0.01% (National Cancer Institute) to 11% (National Institute of Neurological Disorders and Stroke and National Institute of Arthritis and Musculoskeletal and Skin Diseases) of their extramural portfolios. Conclusion Given the extreme burden of trauma-related disability and years of life lost, this review of extramural NIH funding definitively demonstrates that trauma is severely underfunded. The lack of a dedicated home for trauma research at NIH leads to a diffusion of grants across many institutes and makes it impossible to direct a focused and effective national research endeavor to improve outcomes. These data demonstrate the need for a National Institute of Trauma at the NIH to help set an agenda to reach the national goal of Zero Preventable Deaths.

BACKGROUND: This pilot study evaluated whether use of evidence-based implementation strategies to integrate care for cannabis and other drug use into primary care (PC) as part of Behavioral Health Integration (BHI) increased diagnosis and treatment of substance use disorders (SUDs). METHODS: Patients who visited the three pilot PC sites were eligible. Implementation strategies included practice coaching, electronic health record decision support, and performance feedback (3/2015–4/2016). BHI introduced annual screening for past-year cannabis and other drug use, a Symptom Checklist for DSM-5 SUDs, and shared decision-making about treatment options. Main analyses tested whether the proportions of PC patients diagnosed with, and treated for, new cannabis or other drug use disorders (CUDs and DUDs, respectively), differed significantly pre- and post-implementation. RESULTS: Of 39,599 eligible patients, 57% and 59% were screened for cannabis and other drug use, respectively. Among PC patients reporting daily cannabis use (2%) or any drug use (1%), 51% and 37%, respectively, completed an SUD Symptom Checklist. The proportion of PC patients with newly diagnosed CUD increased significantly post-implementation (5 v 17 per 10,000 patients, p

PURPOSE: It is unknown whether receipt of evidence‐based alcohol‐related care varies by rurality among people living with HIV (PLWH) with unhealthy alcohol use—a population for whom such care is particularly important. METHODS: All positive screens for unhealthy alcohol use (AUDIT‐C ≥ 5) among PLWH were identified using Veterans Health Administration electronic health record data (10/1/09–5/30/13). Three domains of alcohol‐related care were assessed: brief intervention (BI) within 14 days, and specialty addictions treatment or alcohol use disorder (AUD) medications (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 1 year of positive screen. Adjusted Poisson models and recycled predictions were used to estimate predicted prevalence of outcomes across rurality (urban, large rural, small rural), clustered on facility. Secondary analyses assessed outcomes in the subsample with documented AUD. FINDINGS: 4,581 positive screens representing 3,458 PLWH (3,112 urban, 130 large rural, and 216 small rural) were included; 49.1% had diagnosed AUD. PLWH in large rural areas had highest receipt of BI (urban 56.6%, 95% CI: 55.0‐58.2; large rural 66.0%, CI: 58.6‐73.5; small rural 60.7%, CI: 54.6‐67.0). PLWH in urban areas had highest receipt of specialty addictions treatment (urban 28.2%, CI: 26.7‐29.8; large rural 19.7%, CI: 13.1‐26.2; small rural 19.6%, CI: 14.1‐25.0). There was no difference in receipt of AUD medications, although overall receipt was low (3%‐4%). Results were similar in the subsample with AUD. CONCLUSION: Among PLWH with unhealthy alcohol use, those in rural areas may be vulnerable to under‐receipt of specialty addictions treatment. Targeted interventions may help ensure PLWH receive recommended care regardless of rurality.

Effective mentoring is a key mechanism propelling successful research and academic careers, particularly for early career scholars. Most mentoring programs focus on models pairing senior and early career researchers, with limited focus on peer mentoring. Peer mentoring may be especially advantageous within emerging areas such as implementation science (IS) where challenges to traditional mentoring may be more prevalent. This special communication highlights the value of peer mentoring by describing a case study of an early career IS peer mentoring group. We delineate our curriculum and structure; support and processes; and products and outcomes. We highlight important group member characteristics to consider during group formation and continuation. The group’s long-term (6 years) success was attributed to the balance of similarities and differences among group members. Members were in a similar career phase and used similar methodologies but studied different health topics at different institutions. Group members gave and received instrumental and psychosocial support and shared resources and knowledge. Peer mentoring can serve an important function to provide emotional, logistical, and professional development support for early career scholars. Our case study highlights strategies to foster peer mentoring groups that provide a generalizable blueprint and opportunity for improved outcomes for early career professionals.

OBJECTIVE To assess the association between debt burden and self-reported suicide attempt among US adults. METHODS Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) were used to estimate the association between self-reported past-year debt burden and past-year and lifetime suicide attempt with logistic regression, controlling for sociodemographic characteristics with known associations with debt burden and suicide attempt. RESULTS Among 36,278 adults aged ≥ 18 years, 13.03% reported past-year debt burden, 0.37% reported past-year suicide attempt, and 5.16% reported lifetime suicide attempt. Self-reported attempt was more likely for persons reporting debt burden than for those without (eg, for past-year suicide attempt: odds ratio [OR] = 7.96 [95% CI, 5.45-11.64; P

Purpose/Objective(s) Standard of care for surgical candidates with locally advanced esophageal/gastroesophageal junction (E/GEJ) cancers is trimodality therapy. Similar to other groups, we have previously demonstrated the strong prognostic significance of pathological complete response (pCR) at the time of esophagectomy. Little is known about the prognostic significance of nodal clearance alone, however. We sought to determine the prognostic significance of nodal clearance in the subgroup of node positive E/GEJ (N+ E/GEJ), hypothesizing that nodal clearance drives the improved outcomes seen in patients with pCR as the primary tumor is more completely removed at esophagectomy. Materials/Methods Patients undergoing TMT for a primary N+ E/GEJ cancer from 1993-2020 within a single institution were retrospectively analyzed. All patients had either clinically involved nodal disease prior to nCRT and/or pathologically confirmed residual nodal disease at time of esophagectomy. Cancer and demographic features were collected. Direct comparisons were made between pCR versus no pCR and nodal clearance (ypN0) versus persistent nodal disease (ypN+) using the Kaplan-Meier method to estimate progression free survival (PFS) and overall survival (OS). Results One hundred eighty-one patients with median follow up of 140 months were included for analysis. Median age at diagnosis was 60.1 years (30.1-80.9), 142 (78.5%) were adenocarcinomas, 102 (56.4%) were AJCC stage IIIA. Fifty-one (28.2%) had pCR, 103 (56.9%) had ypN0 (including 52 [28.7%] with nodal clearance and residual tumor) and 78 (43.1%) had ypN+. Median OS and PFS for the entire cohort were 26.4 (95% CI, 20.5-32.3) and 18.0 months (95% CI, 12.7-23.4), respectively; 2-year local control rate was 87.4% (95% CI, 84.6-90.2). When comparing ypN0 to ypN+, there were statistically significant improvements in OS and PFS. In contrast, there were no significant differences in OS and PFS when comparing patients with pCR to no pCR (Table 1). Conclusion While pCR is a known prognostic factor in E/GEJ regardless of nodal status, in the high-risk subset of N+ E/GEJ patients, nodal clearance was associated with significantly improved OS and PFS regardless of primary tumor response. This is a novel observation and warrants similar hypothesis testing in other data sets and may have implications for therapy in node positive patients.

Background Elderly rib fracture patients are generally admitted to an ICU which may result in overutilization of scarce resources. We hypothesized that this practice results in significant overtriage. Methods Retrospective study of patients over age 70 with acute rib fracture(s) as sole indication for ICU admission. Primary outcomes were adverse events (intubation, pneumonia, death), which we classified as meriting ICU admission. We utilized Cribari matrices to calculate triage rates. Results 101 patients met study criteria. 12% had adverse events occurring on average at day 5. Our undertriage rate was 6% and overtriage rate 87%. The 72 overtriaged patients utilized 295 total ICU days. Evaluating guideline modification, ≥3 fractures appears optimal. Changing to this would have liberated 50 ICU days with 3% undertriage. Conclusion Elderly patients with small numbers of rib fractures are overtriaged to ICUs. Modifying guidelines to ≥3 rib fractures will improve resource utilization and save ICU beds.

Background Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets. Methods We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013–6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge. Results Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge. Conclusion Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.

OBJECTIVE: Alcohol use is understudied among transgender persons—persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD: National VA electronic health record data were used to identify all patients’ last documented Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) screen (October 1, 2009–July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS: Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS: This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.

BACKGROUND/OBJECTIVE: Evidence-based alcohol-related care–brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)–should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. METHODS: We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0–14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0–365 days following screening), and filled prescriptions for medications to treat AUD (documented 0–365 days following screening) for transgender patients, and compared to that of non-transgender patients. RESULTS: Among transgender Veterans with unhealthy alcohol use (N=1,392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2 – 78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7 – 17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1 – 20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98 – 1.04, p=0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12 – 1.37, p

OBJECTIVE: To describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018). DATA SOURCES/STUDY SETTING: Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN: Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS: Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING: Implementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS: When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.

Background Tracheostomy improves outcomes for critically ill patients requiring prolonged mechanical ventilation. Data are limited on the use and benefit of tracheostomies for intubated, critically ill coronavirus disease 2019 (COVID-19) patients. During the surge in COVID 19 infections in metropolitan New York/New Jersey, our hospital cared for many COVID-19 patients who required prolonged intubation. This study describes the outcomes in COVID-19 patients who underwent tracheostomy. Methods We present a case series of patients with COVID-19 who underwent tracheostomy at a single institution. Tracheostomies were performed on patients with prolonged mechanical ventilation beyond 3 wk. Patient demographics, medical comorbidities, and ventilator settings prior to tracheostomy were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes included time on mechanical ventilation, length of ICU and hospital stay, and discharge disposition. Results Fifteen COVID-19 patients underwent tracheostomy at an average of 31 d post intubation. Two patients (13%) died. Half of our cohort was liberated from the ventilator (8 patients, 53%), with an average time to liberation of 14 ± 6 d after tracheostomy. Among patients off mechanical ventilation, 5 (63%) had their tracheostomies removed prior to discharge. The average intensive care length of stay was 47 ± 13 d (range 29-74 d) and the average hospital stay was 59 ± 16 d (range 34-103 d). Conclusions This study reports promising outcomes in COVID-19 patients with acute respiratory failure and need for prolonged ventilation who undergo tracheostomy during their hospitalization. Further research is warranted to establish appropriate indications for tracheostomy in COVID-19 and confirm outcomes.

In Ukraine, a retrospective review of clinical case reports by public health officials suggest that human cases of febrile illnesses associated with hemorrhage may be due to infections of Crimean-Congo hemorrhagic fever virus (CCHFV) and Old World hantaviruses. In a serosurvey of 966 healthy individuals in the Lviv Oblast, Ukraine, bordering Poland, we found that 1.6% showed cross-reactivity to hantaviral antigens by an immunofluorescence assay (IFA) and 1.7% of the study participants had antibodies cross-reactive to CCHFV by enzyme-linked immunosorbent assay (ELISA). Demographic variables and history of exposures obtained through questionnaires were assessed by logistic regression models for association with seroprevalence for both viruses with no significant risk factors found. Analysis of spatial distribution identified two clusters of samples positive for antibodies to both hantaviruses and CCHFV, which, however, were not statistically significant (p > 0.05). In general, the study results suggest that the population of the study area is exposed to hantaviruses and CCHFV. Further surveillance for respective pathogens in Ukraine is warranted and prospective surveillance of febrile patients with unidentified febrile illness.

Background Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care. Method This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care. Results Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03–1.21) or daily (HR = 1.24; 1.10–1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13–1.59), weekly (HR = 2.21; 1.46–3.35), or daily (HR = 2.53; 1.86–3.45) had greater risk of acute care than those reporting no other drug use. Conclusion Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

OBJECTIVE: To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation. METHODS: Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010–6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visit-level analyses, accounting for correlation between individuals’ assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any versus none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year. RESULTS: Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23–15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77–9.72). Among patients reporting no suicidal ideation, no associations were observed. CONCLUSIONS: Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation.

The distribution and abundance of Phlebotomus papatasi, the primary vector of zoonotic cutaneous leishmaniasis in most semi-/arid countries, is a major public health challenge. This study compares several approaches to model the spatial distribution of the species in an endemic region of the disease in Golestan province, northeast of Iran. The intent is to assist decision makers for targeted interventions. We developed a geo-database of the collected Phlebotominae sand flies from different parts of the study region. Sticky paper traps coated with castor oil were used to collect sand flies. In 44 out of 142 sampling sites, Ph. papatasi was present. We also gathered and prepared data on related environmental factors including topography, weather variables, distance to main rivers and remotely sensed data such as normalized difference vegetation cover and land surface temperature (LST) in a GIS framework. Applicability of three classifiers: (vanilla) logistic regression, random forest and support vector machine (SVM) were compared for predicting presence/absence of the vector. Predictive performances were compared using an independent dataset to generate area under the ROC curve (AUC) and Kappa statistics. All three models successfully predicted the presence/absence of the vector, however, the SVM classifier (Accuracy = 0.906, AUC = 0.974, Kappa = 0.876) outperformed the other classifiers on predicting accuracy. Moreover, this classifier was the most sensitive (85%), and the most specific (93%) model. Sensitivity analysis of the most accurate model (i.e. SVM) revealed that slope, nighttime LST in October and mean temperature of the wettest quarter were among the most important predictors. The findings suggest that machine learning techniques, especially the SVM classifier, when coupled with GIS and remote sensing data can be a useful and cost-effective way for identifying habitat suitability of the species.

Background Prior to routine CT scanning, first rib fractures (FRFs) were considered a harbinger of great vessel injuries. We hypothesized FRFs identified on screening CXR have significant associated injuries, while those identified on CT alone do not. Methods We reviewed adult blunt thoracic trauma patients 2014–2015 to identify all FRFs and then tabulated demographics, injury characteristics, and outcomes. Results Of 429 patients with chest trauma, 56 had a FRF. CXR diagnosed 20% and CT 80%. Those diagnosed on CXR were older (61 vs 48 p = 0.03), had more severe chest trauma (45% vs 13% chest AIS>3, p = 0.029), longer ICU stays (10 vs 4 days, p = 0.046), and risk for intubation (73% vs 27%, p = 0.011). There was only one major vascular injury in each group. Most FRF patients had associated injuries, including 82% with pelvic fractures. Conclusions Widespread use of CT scanning has resulted in a 5-fold increase in FRF diagnoses. While vascular injuries are not common, especially when identified on initial CXR, FRFs correlate with morbidity and associated injuries.

The lone star tick, Amblyomma americanum, is the most commonly reported human-biting tick in the southeastern United States and is a vector for several human and livestock pathogens. Although it is endemic to Florida, little is known about the ecological preferences and current spatial distribution within the state. Using occurrence records of adult A. americanum collected between August 2015 and September 2016, a logistic regression model was used to estimate environmental associations, as well as to predict the distribution of the tick at a one hectare resolution. Occurrence of adult lone star ticks was associated with land cover and bioclimatic variables, namely the presence of forested areas and precipitation seasonality. The estimated spatial distribution indicated that central and northern regions show greater suitability than the southern half of the state. Furthermore, areas predicted to be suitable for the species decreases from north to south with very little area deemed suitable in the far southern reaches of the state. High heterogeneity in the distribution of suitable habitat has implications for the distribution of tick-borne disease cases in the state. The subcounty resolution of the estimated distribution is an improvement over distributions currently published and may better inform the public and state or federal agencies of potential risk of exposure to A. americanum and its associated pathogens.

OBJECTIVES. To examine factors that account for women veterans’ higher prevalence of past-year DSM-5 posttraumatic stress disorder (PTSD) compared to women civilians and men veterans. METHODS. Cross-sectional analyses of the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Face-to-face interviews with 379 women veterans, 20,007 women civilians, and 2,740 men veterans were conducted. Trauma type (child abuse, interpersonal violence, combat or war zone, and other), number of trauma types, past-year stressful life events, current social support, and DSM-5 PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Generalized linear models were used that accounted for the complex survey design. RESULTS. Women veterans had a higher unadjusted prevalence of past-year PTSD (11.40%) compared to their civilian (5.96%) and male (5.19%) counterparts. Individual predictor models indicated that the difference between women veterans’ and civilians’ prevalence of PTSD was attenuated when adjusting for number of trauma types, whereas the difference between men and women veterans was attenuated when adjusting for child abuse, interpersonal violence, and stressful life events. Nonetheless, while full adjustment in a multiple predictor model accounted for the difference in PTSD between women veterans and civilians, gender differences between men and women veterans remained. CONCLUSIONS. Number of trauma types, type of trauma, and social factors may together help explain women veterans’ higher PTSD prevalence compared to women civilians, but do not fully account for differences between men and women veterans. Results highlight a need to explore additional explanatory factors and evaluate associations with longitudinal data.

Apert syndrome is characterized by hypertelorism, a negative canthal axis, and central midfacial hypoplasia, resulting in a biconcave face. Bipartition distraction partially corrects these facial anomalies. This study investigates limitations of bipartition distraction using linear, angular, and geometric morphometric analysis. Preoperative and postoperative three-dimensional computed tomographic craniofacial constructs of 10 patients with Apert syndrome (aged 12 to 21 years) were annotated with 98 landmarks. Twelve age-, sex, and ethnicity-matched normal skulls provided control data. Principal component analysis was used to analyze shape characteristics within and between the groups and describe the changes occurring with surgery. Results were displayed graphically using difference color maps. Conventional point-based measurements documented midfacial width, height, and asymmetry. Apert three-dimensional constructs exhibited reduced upper midfacial height and greater extrinsic symmetric variation relative to controls. Facial bipartition partially corrected excessive midfacial width and interorbital distance but did not adequately correct deficient upper midfacial height. Excessive orbital diameter was unaltered by surgery. There was no demonstrable effect on intrinsic or extrinsic midfacial asymmetry. Principal component analysis demonstrated improved midfacial projection and correction of central biconcavity. Bipartition distraction corrects midfacial retrusion, exorbitism, and hypertelorism. It does not treat midfacial height disproportion or correct orbital shape. It leaves the face too wide at the zygomatic level and does not correct facial asymmetry. Although bipartition distraction is an improvement on the unmodified monobloc advancement, further refinements are needed to fully correct Apert dysmorphology.

Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.

Background Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them. Objective This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care. Methods The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data. Results Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel). Conclusions A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients’ needs for structure, support in and outside of visits, and desire for convenience.

OBJECTIVE To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy. DESIGN Retrospective observational cohort study. SETTING Level-I academic trauma center. PATIENTS Adult polytrauma patients with the presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis, or spine, requiring surgical repair (n = 81). INTERVENTION Timing of definitive fracture fixation in relation to the timing of abdominal wall closure. MAIN OUTCOME MEASURE Incidence of orthopedic surgical site infections. RESULTS During a 15-year time window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n = 32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared with group 2 (n = 49) with abdominal wall closure before fixation (mean 4.4 vs. 11.8 days; P = 0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P = 0.002). CONCLUSIONS Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared with delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Despite evidence of alcohol disparities between sexual minority and heterosexual individuals in the general population, research has not examined whether there are disparities in receipt of alcohol screening and brief intervention − together considered one of the highest prevention priorities for US adults. This study examined differences in alcohol use and receipt of alcohol screening and brief intervention across sexual minority status. Methods Behavioral Risk Factor Surveillance System 2014 data from eight US states were used to estimate patterns of alcohol use and receipt of alcohol screening and brief intervention among persons reporting sexual orientation and a checkup in the last two years (N = 47,800). Analyses were conducted in 2016–2017. Results Gay men and bisexual women reported higher rates of alcohol use on some measures compared to heterosexual men and women, respectively. There were some differences in screening and brief intervention by sexual orientation. Lesbian women were more likely to report being asked about heavy episodic drinking than heterosexual women, and among those reporting unhealthy alcohol use, gay men were less likely, and bisexual men were more likely, to report receiving brief intervention compared to heterosexual men. Conclusions Overall similarities between sexual minorities and heterosexuals in alcohol use and receipt of screening and brief intervention are encouraging. Nonetheless, research is needed to confirm findings and understand mechanisms underlying disparities in receipt of brief intervention between gay and heterosexual men.

Summary Background National enhanced surveillance of Staphylococcus aureus Bacteraemia (SAB) commenced on the 1 st of October 2014 to gain a more in-depth understanding of the epidemiology of SAB within Scotland. Children under 16 were analysed separately from adults because previous studies had demonstrated differences in the epidemiology. Aim The aim was to identify risk factors and patient populations most at risk to allow focused improvement plans to be developed. Methods All NHS Boards within NHS Scotland took part in the mandatory enhanced surveillance collecting data by trained data collectors using nationally agreed definitions. Findings Analysis of the first 18 months of data has highlighted that hospital acquired SAB were mostly associated with neonates with device risk factors, whereas Community associated SAB were found in older children who had few if any risk factors and most presented with a bone or joint infection. Conclusion The enhanced SAB data has highlighted the difference in risk factors and entry points for the acquisition of SAB within the paediatric population.

Background: Negative pressure wound therapy is a ubiquitous wound management resource. The influence of NPWT on the bacterial bioburden of the subjacent wound remains unclear. We sought to examine the evidence. Datasources: MEDLINE, Embase, PubMed, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register were searched for articles quantitatively evaluating bacterial load under NPWT. Results: Twenty-four studies met the inclusion criteria including 4 randomised controlled trials, 8 clinical series and 12 experimental studies. Twenty studies evaluated conventional NPWT while 4 evaluated Infiltration-based NPWT. While 8 studies using conventional NPWT failed to demonstrate an observable effect on bacterial load, 7 studies reported that NPWT was inherently bacteriostatic and 5 others reported species selectivity with suppression of non-fermentive Gram-negative bacilli (NFGNB), including pseudomonas spp. Simultaneously, there was some evidence of enhanced proliferation of Gram-positive cocci where the niche was cleared of NFGNB. Two of the 4 studies using infiltration-based NPWT also reported selectively impaired proliferation of pseudomonas spp. Conclusion: The assumption that NPWT suppresses bacterial proliferation is oversimplified. There is evidence that NPWT exhibits species selectivity, suppressing the proliferation of NFGNB. However, this may depopulate the niche for exploitation by Gram-positive cocci. This, in turn, has implications for the use of NPWT where highly virulent strains of Gram-positive cocci have been isolated, as well as the duration of NPWT therapy and frequency of dressing changes.

BACKGROUND Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge. METHODS Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups. RESULTS Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p

Background We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking. Methods We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization. Results Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%. Conclusions The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

For the large scale fuel cell manufacture, the catalyst loading and layer thickness are critical factors affecting the performance and cost of membrane electrode assemblies (MEAs). The influence of catalyst layer thicknesses at the anode of a PEM based direct methanol fuel cell (DMFC) has been investigated. Catalysts were applied with the drawdown method with varied thicknesses ranging from 1 mil to 8 mils (1 mil = 25.4 μm) with a Pt/Ru anode loading of 0.25 mg cm-2 to 2.0 mg cm-2. The MEAs with the thicker individual layers (8 mils and 4 mils) performed better overall compared to the those with the thinner layers (1 mil and painted). The peak power densities for the different loading levels followed an exponential decrease of Pt/Ru utilization at the higher loading levels. The highest power density achieved was 49 mW cm-2 with the 4 mil layers at 2.0 mg cm-2 catalyst loading whereas the highest normalized power density was 116 mW mg-1 with the 8 mil layers at 0.25 mg cm-2 loading. The 8 mil drawdowns displayed a 50% and 23% increase in normalized power density compared to the 1 mil drawdowns at 0.25 mg cm-2 and 0.5 mg cm-2 loadings, respectively.

Background Complex surgery for appearance change is controversial. Correction of orbital hypertelorism risks diplopia and loss of stereopsis for aesthetic gain. The risk-to-benefit ratio remains ill-defined. The aim of this study was to define specific ocular morbidity following orbital translocation. Methods The authors compared stable preoperative and postoperative orthoptic indices (i.e., angle of strabismus, ocular motility, and acuity) for 23 consecutive patients who underwent orbital translocation between 2000 and 2015 and noted the requirement for corrective surgery. Results Eighteen patients underwent 33 box osteotomies (15 bilateral and three unilateral). Five patients underwent facial bipartition. Diagnosis was craniofrontonasal dysplasia in 11, frontonasal dysplasia in six, facial cleft in four, and Saethre-Chotzen syndrome in two cases. Median grade of orbital hypertelorism was III. Median age at surgery was 13 years (range, 5 to 17 years). Nontransient change (favorable or unfavorable) in angle of strabismus was noted in 14 patients. Ocular motility was altered in 12. Six patients had stereopsis preoperatively that was disrupted in two cases because of changes in ocular alignment and/or motility. There was one perioperative ophthalmic emergency (superior orbital fissure syndrome) and three acute reexplorations for external ocular muscle entrapment. Corrective surgery for strabismus was performed for four patients. Three required secondary canthopexy and three required surgery for blepharoptosis. Conclusions Orbital translocation is associated with ocular risks including changes to angle of strabismus, ocular motility, and (when present) loss of stereopsis. Secondary surgery to correct strabismus or eyelid malposition is common. Orbital translocation is an operative process, not a single procedure. Clinical question/level of evidence Therapeutic, IV.

Injuries to the hand during military combat operations, particularly from improvised explosive devices (IEDs) have a significant impact on form, function, mental health and future employment but remain underreported amidst the life and limb-threatening emergencies that garner more attention. An understanding the patterns of hand injuries encountered from IEDs is crucial to optimizing reconstruction and rehabilitation. The aim of this study was to re-evaluate hand injury sustained from IED in order to understand the clinical burden for reconstruction and direct the focus for future hand protection. We identified 484 hand injuries in 380 patients sustained as a result of IEDs among military personnel service in Afghanistan between 2006 and 2013. 53% of all surviving military personnel injured by IEDs sustain injuries to the hand. Analysis of the 103 patients who sustained injury to the metacarpal, phalanges or digital amputation revealed that the middle and ring fingers are most commonly injured. Amputation to the ring finger is strongly associated with injury to the adjacent fingers and amputations to the middle, ring and little fingers concurrently is a commonly observed pattern. The proximal phalanges of the middle and ring fingers had a strong correlation for fracture together. These findings disprove the conventional belief in an ulnar focus of injury and support the quest for a development of combat hand protection that addresses the injury pattern seen.

Objective Specialty addictions treatment can improve outcomes for patients with alcohol use disorders (AUD). Thus, initiation of and engagement with specialty addictions treatment are considered quality care for patients with AUD. Previous studies have demonstrated racial/ethnic differences in alcohol-related care but whether differences exist in initiation of and engagement with specialty addictions treatment among patients with clinically recognized alcohol use disorders is unknown. We investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA). Methods National VA data were extracted for all Black, Hispanic, and White patients with a diagnosed AUD during fiscal year 2012. Mixed effects regression models estimated the odds of two measures of initiation (an initial visit within 180 days of diagnosis; and initiation defined consistent with Healthcare Effectiveness Data and Information Set (HEDIS) as a documented visit ≤14 days after index visit or inpatient admission), and three established measures of treatment engagement (≥3 visits within first month after initiation; ≥2 visits in each of the first 3 months after initiation; and ≥2 visits within 30 days of HEDIS initiation) for Black and Hispanic relative to White patients after adjustment for facility- and patient-level characteristics. Results Among 302,406 patients with AUD, 30% (90,879) initiated treatment within 180 days of diagnosis (38% Black, 32% Hispanic, and 27% White). Black patients were more likely to initiate treatment than Whites for both measures of initiation [odds ratio (OR) for initiation: 1.4, 95% confidence interval (CI) 1.4–1.4; OR for HEDIS initiation: 1.1, 95% CI: 1.1–1.1]. Hispanic patients were more likely than White patients to initiate treatment within 180 days (OR: 1.2, 95% CI 1.2–1.3) but HEDIS initiation did not differ between Hispanic and White patients. Engagement results varied depending on the measure but was more likely for Black patients relative to White for all measures (OR for engagement in first month: 1.1, 95% CI: 1.0–1.1; OR for engagement in first three months: 1.2, 95% CI: 1.1–1.2; OR for HEDIS measure: 1.1, 95% CI: 1.0–1.1), and did not differ between Hispanic and White patients. Conclusions After accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage. Research is needed to understand underlying mechanisms and whether differences in initiation of and engagement with care influence health outcomes.