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Background Limited data describes the effectiveness of strategies to optimize naloxone rescue kit distribution. Mental health clinical pharmacy specialists (CPS) at VA St. Louis HCS aimed to increase distribution of naloxone rescue kits to patients with Opioid Use Disorder (OUD). An informational letter detailing the purpose of rescue kits and how to obtain one were sent to patients with OUD who had no active order for a naloxone rescue kit within the previous year. Roughly half of these patients were targeted for follow-up education via telephone. Methods A retrospective study was conducted comparing the effectiveness of these contact methods. Study groups included those contacted by letter alone and those contacted by both letter and phone call. The primary outcome was order placement for a rescue kit within 90 days of contact. Post-hoc analysis included a multivariate regression, case-control evaluation of variables potentially associated with kit distribution. Results In total, 335 patients were included. Of 185 patients targeted for phone follow-up, 81 were reached (43.8%), and 254 received the letter alone. The primary outcome was achieved by 13 (5.1%) and 52 (64.2%) participants in the letter alone and letter plus phone contact groups, respectively ( p Conclusions In patients with OUD, those contacted by phone in addition to receiving a letter were significantly more likely to receive a naloxone kit than those contacted via letter alone. In addition to contact by phone, nonwhite race, prior participation in rehabilitation and active opioid prescription were associated with a higher rate of kit obtainment.

Central venous and arterial access through minimally invasive techniques has been described in adult pigs. This article demonstrates success in juvenile animals. Using ultrasound guidance and the modified Seldinger technique, 5 Fr/15 cm single-lumen central venous catheters and 20 Ga 4.5 cm femoral arterial catheters were placed in six Yorkshire cross-bred swine. All six cases had no loss of venous catheter patency or infection during the 96-hour follow-up period. Arterial catheters remained patent, and no significant bleeding was noted after removal.

Introduction: This study reports the global occurrence of passenger and crew mortality on cruise ships. To date, no comprehensive study of passenger and crew mortality has been published. Methods: All data on passenger and crew mortality between 2000 and 2019 were obtained from 78 ocean and river cruise lines registered globally and analyzed by their age, gender, nationality, cruise line, and recorded cause of death. Results: There were 623 reported deaths. Out of all deaths, 89% were passenger deaths and 11% were crew deaths. United States residents accounted for 61% of passenger deaths and crew from India (18%) and the Philippines (17%) recorded the highest crew deaths. Falls overboard or onto lower decks (23%), suicide, murder, and a terror attack (19%), unspecified natural causes (18%), and cardiac incidents (16%) were the primary causes of passenger deaths. Suicide and murder (29%) and falls overboard or from height (24%) were the primary cause of crew member deaths. The most passenger deaths occurred on Carnival Cruise Lines (29%), Royal Caribbean Cruises (12%), and Norwegian Cruise Line (10%). The highest crew member deaths occurred on Carnival Cruise Line (19%) and Royal Caribbean Cruises (19%). Conclusion: Falls overboard or onto lower decks, cardiac incidents, and suicides are the leading cause of passenger deaths. Suicide and murder and falls are the leading cause of death for crew members. Travel health advisories targeting US citizen passengers and crew members from India and the Philippines are warranted. The addition of mental health care to ship infirmaries is also suggested.

Accurate measurement of skin lesions influences diagnosis, treatment, disease monitoring, prognosis, and even reimbursement in the practice of dermatology. As dermatologists expand technology that is integrated in patient care, measurement has the opportunity to become more accurate, more easily integrated into daily practice, and more easily incorporated into the realm of research. Herein, we review the benefits, limitations, and future direction of augmented reality (AR) in relationship to measurement of dermatologic conditions. This can include simple linear dimensions, area calculations, and even assessments that will drive clinical interventions. Additionally, we highlight current baseline mobile application tools that may lay the groundwork for further validation, augmentation, and utility of these technologies.

Supplemental Digital Content is Available in the Text. Estimated peak oxygen uptake (V˙o2peak) using 6-min Walk Test distance demonstrated poor agreement with measured V˙o2peak from a cardiopulmonary exercise test in patients with heart failure enrolled in cardiac rehabilitation., Purpose: We examined the agreement between peak oxygen uptake (V˙o2peak), estimated using prediction equations from the 6-min Walk Test (6MWT), and V˙o2peak measured using a cardiopulmonary exercise test (CPX) to estimate change in V˙o2peak in patients with heart failure (HF) enrolled in cardiac rehabilitation (CR). Methods: This was secondary analysis of 54 (including 9 women) patients with HF who completed a clinical CR program. Four previously published equations using 6MWT distance were used to estimate V˙o2peak and were compared with a CPX at baseline, follow-up, and change using the standard and modified Bland-Altman method. Analyses were repeated for quartiles of cardiorespiratory fitness (CRF) based on measured V˙o2peak from the CPX. Results: Bland-Altman plots revealed proportional bias between all prediction equations and the measured V˙o2peak. The difference between methods varied by the level of CRF, with overestimation of prediction equations at greater levels of CRF and underestimation at lower levels of CRF. This poor agreement remained when comparisons were made between the estimated and measured V˙o2peak values at quartiles of CRF, indicating prediction equations have limited ability to predict V˙o2peak at any level of CRF. Conclusion: Estimated V˙o2peak using 6MWT distance demonstrated poor agreement with measured V˙o2peak from a CPX. While distance ambulated on the 6MWT remains an important measure of physical performance in patients with HF, prediction equations using 6MWT distance are not appropriate to monitor changes in V˙o2peak following CR in patients with HF.

Prophylactic cranial irradiation (PCI) is used to decrease the probability of developing brain metastases in patients with small cell lung cancer and has been linked to deleterious cognitive effects. Although no well-established imaging markers for these effects exist, previous studies have shown that structural and metabolic changes in the brain can be detected with MRI and PET. This study used an image processing technique called texture analysis to explore whether global changes in brain glucose metabolism could be characterized in PET images. Methods:18F-FDG PET images of the brain from patients with small cell lung cancer, obtained before and after the administration of PCI, were processed using texture analysis. Texture features were compared between the pre- and post-PCI images. Results: Multiple texture features demonstrated statistically significant differences before and after PCI when texture analysis was applied to the brain parenchyma as a whole. Regional differences were also seen but were not statistically significant. Conclusion: Global changes in brain glucose metabolism occur after PCI and are detectable using advanced image processing techniques. These changes may reflect radiation-induced damage and thus may provide a novel method for studying radiation-induced cognitive impairment.

Can a previously defined relationship between sperm capacitation and the probability of a man generating pregnancy within three cycles, prospectively predict male fertility in diverse clinical settings? A second study asked, what is the prevalence of impaired sperm fertilizing ability in men questioning their fertility (MQF), and does this relate to traditional semen analysis metrics?In the multicentric, prospective observational study, data (n = 128; six clinics) were analysed to test a published relationship between the percentage of fertilization-competent, capacitated spermatozoa (Cap-Score) and probability of generating pregnancy (PGP) within three cycles of intrauterine insemination. Logistic regression of total pregnancy outcomes (n = 252) assessed fit. In the cohort comparison, Cap-Scores of MQF (n = 2155; 22 clinics) were compared with those of 76 fertile men.New outcomes (n = 128) were rank-ordered by Cap-Score and divided into quintiles (25-26 per group); chi-squared testing revealed no difference between predicted and observed pregnancies (P = 0.809). Total outcomes (n = 252; 128 new + 124 previous) were pooled and the model recalculated, yielding an improved fit (P0.001). Applying the Akaike information criterion found that the optimal model used Cap-Score alone. Cap-Scores were performed on 2155 men (with semen analysis data available for 1948). To compare fertilizing ability, men were binned by PGP (≤19%, 20-29%, 30-39%, 40-49%, 50-59%, ≥60%). Distributions of PGP and the corresponding Cap-Scores were significantly lower in MQF versus fertile men (P0.001). Notably, 64% of MQF with normal volume, concentration and motility (757/1183) had PGP of 39% or less (Cap-Scores ≤31), versus 25% of fertile men.Sperm capacitation prospectively predicted male fertility. Impaired capacitation affects many MQF with normal semen analysis results, informing diagnosis versus idiopathic infertility.

The bladder exstrophy-epispadias complex is a very rare and complex spectrum of congenital anomalies. The holy grail of treatment for BEEC is volitional voiding with preservation of the upper tracts and patient satisfaction. The development of a collaboration can increase the exposure and experience for a panel of surgeons to better improve the care of babies with this anomaly, both in the surgical correction and in the pre- and post-operative care. The reported outcomes after exstrophy repair vary widely due to different approaches to closure as well as the variable outcome measures used to report experiences. While it is yet too soon to report on final continence outcomes, over the last 6 years, a collaboration between three institutions has increased by three-fold the experience for every individual under the guidance of an experienced coach. The treatment of patients with bladder exstrophy and epispadias is a complex anatomic and physiologic process that requires careful attention to a precise surgery while also focusing on the long-term growth of the bladder and keeping the upper tracts safe. This collaboration, which is predicated on a dedicated team with a focused target, has increased experience and exposure to exstrophy for all institutions.

This article describes a secondary data analysis of a health data set representing the experiences of abortion fund service recipients (ASRs) who received financial assistance to help pay for unaffordable abortion costs. The authors analyzed 3,216 ASR cases from 2001 to 2015. Demographic characteristics, service utilization rates, and the personal hardships reported by the sample were assessed. The personal hardships of the Florida ASRs were compared with the hardships reported by ASRs who received assistance from a national fund. Results indicate that Florida ASRs are primarily people of color who are single, in their mid-20s, already parenting children, and receiving assistance in the second trimester of pregnancy. ASRs in this current study are experiencing multiple personal hardships while trying to access an abortion, including economic hardships (such as lack of insurance coverage and unemployment) and trauma (including rape and partner violence). When compared with the ASRs at the national level, these state-level ASRs reported higher rates of unemployment, partner violence, and rape, which suggests that the Florida ASRs face some more dire circumstances compared with ASRs at the national level. Repeal of policy that restricts public funding of abortion in Florida is recommended to improve access to abortion.

Aims Arthrofibrosis is a relatively common complication after joint injuries and surgery, particularly in the knee. The present study used a previously described and validated rabbit model to assess the biomechanical, histopathological, and molecular effects of the mast cell stabilizer ketotifen on surgically induced knee joint contractures in female rabbits. Methods A group of 12 skeletally mature rabbits were randomly divided into two groups. One group received subcutaneous (SQ) saline, and a second group received SQ ketotifen injections. Biomechanical data were collected at eight, ten, 16, and 24 weeks. At the time of necropsy, posterior capsule tissue was collected for histopathological and gene expression analyses (messenger RNA (mRNA) and protein). Results At the 24-week timepoint, there was a statistically significant increase in passive extension among rabbits treated with ketotifen compared to those treated with saline (p = 0.03). However, no difference in capsular stiffness was detected. Histopathological data failed to demonstrate a decrease in the density of fibrous tissue or a decrease in α-smooth muscle actin (α-SMA) staining with ketotifen treatment. In contrast, tryptase and α-SMA protein expression in the ketotifen group were decreased when compared to saline controls (p = 0.007 and p = 0.01, respectively). Furthermore, there was a significant decrease in α-SMA (ACTA2) gene expression in the ketotifen group compared to the control group (p < 0.001). Conclusion Collectively, these data suggest that ketotifen mitigates the severity of contracture formation in a rabbit model of arthrofibrosis. Cite this article: Bone Joint Res 2020;9(6):302–310.

The financial impact of the rising number of pediatric mental health hospitalizations is unknown. Therefore, this study assessed costs, reimbursements, and net profits or losses for 111,705 mental health and non–mental health medical hospitalizations in children’s hospitals with use of the Pediatric Health Information System and Revenue Management Program. Average financial margins were calculated as (reimbursement per day) – (cost per day), and they were lowest for mental health hospitalizations ($136/day), next lowest for suicide attempt ($518/day), and highest for other medical hospitalizations ($611/day). For 10 of 17 hospitals, margin per day for mental health hospitalizations was lower than margin per day for other medical hospitalizations. For these 10 hospitals, the total net loss for inpatient and observation status mental health hospitalizations, compared with other medical hospitalizations, was $27 million (median, $2.2 million per hospital). Financial margins were usually lower for mental health vs non–mental health medical hospitalizations. Journal of Hospital Medicine 2020;15:727- 730. © 2020 Society of Hospital Medicine

BACKGROUND AND OBJECTIVES To determine the efficacy of targeted fluorescent biomarkers and multiphoton imaging to characterize early changes in ovarian tissue with the onset of cancer. STUDY DESIGN/MATERIALS AND METHODS A transgenic TgMISIIR-TAg mouse was used as an animal model for ovarian cancer. Mice were injected with fluorescent dyes to bind to the folate receptor α, matrix metalloproteinases, and integrins. Half of the mice were treated with 4-vinylcyclohexene diepoxide (VCD) to simulate menopause. Widefield fluorescence imaging (WFI) and multiphoton imaging of the ovaries and oviducts were conducted at 4 and 8 weeks of age. The fluorescence signal magnitude was quantified, and texture features were derived from multiphoton imaging. Linear discriminant analysis was then used to classify mouse groups. RESULTS Imaging features from both fluorescence imaging and multiphoton imaging show significant changes (P

PURPOSE OF REVIEW: The purposes of this review are to describe the epidemiology, treatment options, and clinical outcomes of revision medial ulnar collateral ligament reconstruction in baseball pitchers. RECENT FINDINGS: Rates of revision UCL range from 1 to 15% and have slowly increased over the past several years. Revision UCL procedures are associated with higher complication rates, likely due to the distortion of innate anatomy after primary reconstruction. Techniques for reconstruction are largely influenced by the index surgery and integrity of the ulnar and humeral bone tunnels/sockets. Current literature reporting on the outcomes following revision UCL reconstruction is limited to case series and database studies. Mean time between primary reconstruction and revision surgery is approximately 5 years and return to play rates range from 47 to 85%. SUMMARY: Outcomes following revision UCL reconstruction are relatively guarded compared with those of primary UCL reconstruction with the most studies reporting lower return to play rates, decreased workloads compared with pre-injury levels of play, and shorter career longevity following revision surgery. Future research regarding optimal reconstruction techniques and post-operative rehabilitation are needed as the incidence and demand for this procedure is expected to increase.

BACKGROUND: Dermatologic surgery is associated with low postoperative infection rates, averaging from approximately 1% to 4.25%. Often, postoperative infections are treated empirically based on clinical diagnosis of infection, given it can take 48 to 72 hours for a wound culture to identify a pathogen. OBJECTIVE: We aimed to evaluate the efficacy of empiric antibiotics in dermatologic surgery postoperative infections and if wound cultures change postoperative antibiotic therapy. METHODS: A 7-center, retrospective analysis of postoperative infections, with culture data, in dermatologic surgery patients was performed. RESULTS: Of 91 cases of clinically diagnosed postoperative infection, 82.4% (n = 75) were successfully treated with empiric oral antibiotics (95% confidence interval [0.73–0.89], p < .0001). In 16 (17.6%) cases, initial empiric antibiotics were unsuccessful, and wound culture results altered antibiotic therapy in 9 cases (9.9%) with 6 (6.6%) of these cases requiring additional coverage for methicillin-resistant Staphylococcus aureus (MRSA). CONCLUSION: Empiric antibiotic treatment is usually appropriate for patients with postoperative surgical-site infections with wound cultures altering antibiotic management in a minority of cases. When empiric antibiotics fail, lack of MRSA coverage is usually the cause; therefore, providers should be aware of local MRSA prevalence and susceptibilities.

Background: Since the implementation of social distancing practices during the global coronavirus disease 2019 (COVID-19) pandemic there have been a myriad of definitions for ‘social distancing.’ The objective of this study was to determine students’ awareness of the various definitions of social distancing, how strictly they adhered to social distancing guidelines, and how they perceived the importance of various social distancing practices. Methods: This cross-sectional survey was distributed via email to students at Emory-affiliated graduate schools, including the Medical, Nursing, and Public Health Schools. Results: Of the 2,453 recipients of the survey, 415 students responded (16.9% response rate). The majority of respondents were medical students (n=225, 55.6%). Of the respondents, 357 noted that they “frequently” or “always” abided by social distancing. The most common definition of social distancing with which respondents were familiar was the Centers for Disease Control and Prevention (CDC)’s (n=276 of 369 responses, 74.8%). There were significant differences across groups when grouping students by the definition of social distancing that they were aware of, the social distancing guideline they most closely followed, and their school of attendance regarding the importance of specific social distancing examples (p

Background Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. Objective To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. Methods This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. Results Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. Conclusion Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

ObjectiveBystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) improves survival and neurological outcomes. Nonetheless, many OHCA patients do not receive bystander CPR during a witnessed arrest. Our aim was to identify potential barriers to bystander CPR.MethodsParticipants at CPR training events conducted in the USA between February and May 2018 answered a 14-question survey prior to training. Respondents were asked about their overall comfort level performing CPR, and about potential concerns specific to performing CPR on a middle-aged female, a geriatric male, and male and female adolescent patients. Open-ended responses were analysed qualitatively by categorising responses into themes.ResultsOf the 677 participants, 582 (86.0%) completed the survey, with 509 (88.1%) between 18 and 29 years of age, 341 (58.6%) without prior CPR training and 556 (96.0%) without prior CPR experience. Across all four scenarios of patients in cardiac arrest, less than 65% of respondents reported that they would be ‘Extremely Likely’ (20.6%–29.1%) or ‘Moderately Likely’ (26.9%–34.8%) to initiate CPR. The leading concerns were ‘causing injury to patient’ for geriatric (n=193, 63.1%), female (n=51, 20.5%) and adolescent (n=148, 50.9%) patients. Lack of appropriate skills was the second leading concern when the victim was a geriatric (n=41, 13.4%) or adolescent (n=68, 23.4%) patient, whereas for female patients, 35 (14.1%) were concerned about exposing the patient or the patient’s breasts interfering with performance of CPR and 15 (6.0%) were concerned about being accused of sexual assault. Significant differences were observed in race, ethnicity and age regarding the likelihood of starting to perform CPR on female and adolescent patients.ConclusionsParticipants at CPR training events have multiple concerns and fears related to performing bystander CPR. Causing additional harm and lack of skills were among the leading reservations reported. These findings should be considered for improved CPR training and public education.

Ovarian cancer is challenging due to poor detection rates and high mortality. Multispectral fluorescence imaging (MFI) has recently become a favorable method for cancer characterization. By utilizing MFI along with a characterized ovarian cancer mouse model and human fallopian tube histology sections, we were able to study cancer in its earliest stages with a promising modality for early disease detection. Fluorescence images with various emission combinations from 280nm to 550nm excitation and reflectance images from 320nm to 550nm were taken of 8-week-old mouse ovarian tissues. Human fallopian tube histology slides were also imaged with the same fluorescence images. Disease characterization was studied using Quadratic Discriminant Analysis (QDA) on image grayscale intensities for both tissues as well as the greylevel co-occurrence matrix (GLCM) in human tissue slides in order to determine a classification group with the highest predictive merit. Both tissues were able to be classified with greater than 80% accuracy, suggesting promise for MFI as a potential diagnostic candidate.

The laser-induced choroidal neovascularization (CNV) model has been widely used for research on wet age-related macular degeneration (wet-AMD) and other ocular neovascular diseases. In this model, the Bruch membrane is perforated by laser injury, resulting in neovascularization formed from the choroidal capillaries. It has become a standard method to evaluate the effect of different treatments on CNV progression in preclinical studies. This protocol can be used in various species, including rat, mouse, pig, and monkey. The rodent laser-induced CNV model is the most commonly used because of the advantages in both cost- and time-efficiency. It takes only 10-15 min to complete the whole laser procedure after adequate training and practicing the technique. Peak CNV formation occurs at approximately 2 weeks after laser application. The entire protocol may require up to 3 weeks to complete the treatment, fundus image acquisition, and tissue collection for histologic analysis. This chapter describes the detailed procedures, protocols, and useful notes on how to induce CNV by laser.

IMPORTANCE There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs). OBJECTIVE To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs. EVIDENCE REVIEW Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses. FINDINGS The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately >= 20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC. CONCLUSIONS AND RELEVANCE Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Purpose The impact of a focused inpatient educational intervention on rates of medication-assisted therapy (MAT) for veterans with opioid use disorder (OUD) was evaluated. Methods A retrospective cohort analysis compared rates of MAT, along with rates of OUD-related emergency department (ED) visits and/or hospital admission within 1 year, between veterans with a diagnosis of OUD who completed inpatient rehabilitation prior to implementation of a series of group sessions designed to engage intrinsic motivation to change behavior surrounding opioid abuse and provide education about MAT (the control group) and those who completed rehabilitation after implementation of the education program (the intervention group). A post hoc, multivariate analysis was performed to evaluate possible predictors of MAT use and ED and/or hospital readmission, including completion of the opioid series, gender, age (>45 years), race, and specific prior substance(s) of abuse. Results One hundred fifty-eight patients were included: 95 in the control group and 63 in the intervention group. Rates of MAT were 25% (24 of 95 veterans) and 75% (47 of 63 veterans) in control and intervention groups, respectively (P < 0.01). Gender, completion of the opioid series, prior heroin use, and marijuana use met prespecified significance criteria for inclusion in multivariate regression modeling of association with MAT utilization, with participation in the opioid series (odds ratio [OR], 9.56; 95% confidence interval [CI], 4.36-20.96) and prior heroin use (OR, 3.26; 95% CI, 1.18-9.01) found to be significant predictors of MAT utilization on multivariate analysis. Opioid series participation and MAT use were independently associated with decreased rates of OUD-related ED visits and/or hospital admission (hazard ratios of 0.16 [95% CI, 0.06-0.44] and 0.32 [95% CI, 0.14-0.77], respectively) within 1 year after rehabilitation completion. Conclusion Focused OUD-related education in a substance abuse program for veterans with OUD increased rates of MAT and was associated with a decrease in OUD-related ED visits and/or hospital admission within 1 year.

This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data.Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures).In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections.Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

Background: The purpose of this study was to develop a model of ventricular fibrillation arrest with reliable outcomes and minimally invasive methods to study the use of perfluorocarbon emulsions (PFC) as agents to prevent ischemia-reperfusion injury after cardiac arrest as quantified by known biomarkers. Methods: Female Yorkshire swine underwent anesthesia and minimally invasive instrumentation for monitoring under ultrasound. Cardiac arrest was induced with spinal needle insertion at the apex and right parasternal space. Ventricular fibrillation was reliably obtained in all animals on initial attempts. A three-minute circulatory arrest state was observed. Administration of PFC was concurrent with resuscitation including closed chest compressions, epinephrine, amiodarone, and defibrillation at 1J/kg. Primary endpoint was induction of cardiac arrest and tolerance of PFC with return of spontaneous circulation. Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin C-Terminal Hydrolase-L1 (UCLH1) were secondary end points for three animals. Results: Six of six animals were induced into ventricular fibrillation on initial attempt and two of three survival experiments were able to obtain spontaneous circulation. PFC with pretreatment was tolerated well and no signs of increased pulmonary pressures. GFAP, UCHL1 were significantly lower in intervention animals compared to controls. Conclusions: The results obtained from this preliminary study and technical refinements via additional donated animals have allowed us to make modifications in the choice of PFC, vascular access, and anticoagulation plan. This model provides a consistent method for inducing ventricular fibrillation with minimally invasive techniques. The PFC tested was well tolerated. More robust evaluation of PFC as resuscitative agents is needed with appropriately powered studies.

Supplemental Digital Content is available in the text., Objectives: Obtaining informed consent for commonly performed ICU procedures is often compromised by variability in communication styles and inadequate verbal descriptions of anatomic concepts. The objective of this study was to evaluate the efficacy of an audiovisual module in improving the baseline knowledge of ICU procedures among patients and their caregivers. Design: Prospective, observational study. Setting: Forty-eight–bed adult surgical ICU at a tertiary care center. Subjects: Critically ill surgical patients and their legally authorized representatives. Interventions: An audiovisual module describing eight commonly performed ICU procedures. Measurements and Main Results: Fifty-nine subjects were enrolled and completed an 11-question pre- and postvideo test of knowledge regarding commonly performed ICU procedures and a brief satisfaction survey. Twenty-nine percent had a healthcare background. High school was the highest level of education for 37% percent of all subjects. Out of 11 questions on the ICU procedure knowledge test, subjects scored an average 8.0 ± 1.9 correct on the pretest and 8.4 ± 2.0 correct on the posttest (p = 0.055). On univariate logistic regression, having a healthcare background was a negative predictor of improved knowledge (odds ratio, 0.185; 95% CI, 0.045–0.765), indicating that those with a health background had a lower probability of improving their score on the posttest. Among subjects who did not have a healthcare background, scores increased from 7.7 ± 1.9 to 8.3 ± 2.1 (p = 0.019). Seventy-five percent of all subjects indicated that the video was easy to understand, and 70% believed that the video improved their understanding of ICU procedures. Conclusions: Audiovisual modules may improve knowledge and comprehension of commonly performed ICU procedures among critically ill patients and caregivers who have no healthcare background.

Extended Summary Background and Study Objective The value of bilateral ureteral reimplant (BUR) at the time of complete primary repair of bladder exstrophy (CPRE) has been suggested, however, outcomes are poorly characterized in current medical literature. We hypothesize that BUR at time of CPRE will decrease the rate of recurrent pyelonephritis, post-operative vesicoureteral reflux (VUR), and the need for subsequent ureteral surgery. Study Design We analyzed 64 consecutive patients with a diagnosis of classic bladder exstrophy (BE) who underwent CPRE at three institutions from 2013 to 2019. 15 patients underwent cephalotrigonal BUR-CPRE and 49 patients underwent CPRE alone. Our primary outcome was >1 episode of pyelonephritis as documented in the medical record. Secondary outcomes were persistent vesicoureteral reflux (VUR), with a sub-analysis of number of refluxing renal units and presence of dilating VUR, and the need for subsequent ureteral surgery. Descriptive statistics in addition to standard, two tailed univariate statistics, were used to compare the groups where appropriate. Results BUR-CPRE was associated with a significant decrease in the rates of post-operative VUR, number of refluxing renal units, and need for subsequent ureteral surgery (p=0.002, p=0.001, and p=0.048 respectively). There was a reduction in the rates of recurrent pyelonephritis and dilating reflux in patients undergoing BUR-CPRE, though it did not reach significance. Female gender was significantly associated with recurrent pyelonephritis regardless of BUR-CPRE status (p=0.005). There were no reports of distal ureteral obstruction or other complications following BUR-CPRE. The mean post-operative follow up for the BUR-CPRE group was 46.33 (10.26) months vs. 53.76 (26.05) months for CPRE, (p=0.11). Discussion Recurrent pyelonephritis following bladder closure in patients with BE is a well-documented surgical complication, with centers performing CPRE reporting rates of post-operative pyelonephritis from 22 to 50%. Our series demonstrates similar efficacy of BUR-CPRE compared to other contemporary series and provides additional detail about need for subsequent ureteral surgeries and increased long term follow-up of these complex patients. Limitations of the study include male predominance of the cohort and lack of randomization of BUR-CPRE. Conclusions BUR-CPRE decreases postoperative VUR and the need for additional ureteral surgery in select BE patients; it should be considered when technically feasible. While results continue to suggest a trend toward decreased recurrent pyelonephritis and dilating reflux, further longitudinal follow-up in our cohort will be needed.

Background: Left ventricular assist device (LVAD) patients are vulnerable to over-utilization of resources. Methods and results: We explored the pattern of emergency department (ED) presentations of LVAD patients and their costs compared with non-LVAD heart failure patients. ED visits between 7/2008 and 7/2017 were reviewed to identify 145 LVAD patients, and 435 patients with known heart failure were selected using propensity score matching for age and sex. ED evaluation metrics, hospitalization cost, and length of stay (LOS) were analyzed. Although the most common ED presentations and their frequency differed between groups, few were LVAD specific. LVAD patients were more likely to have taken personal vehicles or be flown to the ED. They had similar times to triage, rooming, and physician evaluation compared with non-LVAD patients. However, LVAD patients were noted to have a shorter time from physician assessment to disposition (109.8 min vs. 177.0 min, p

Though known as a medicinal herb for centuries, the recent legalization of cannabinoids across many states has ushered in a new era where cannabinoids have become a popular treatment option among clinicians and patients alike. Cannabinoids have demonstrated efficacy in wound healing, reducing inflammation, ameliorating pain, and have shown potential as an antitumor agent. As a result, cannabinoids have been rapidly woven into the fabric of modern medicine. However, the utility of cannabinoids in dermatologic surgery has not been explored to date. In this article, we review the current literature to discuss the potential impact of cannabinoid use in dermatologic surgery.

Neonates are at an increased risk of bacterial sepsis due to the unique immune profile they display in the first months of life. We have established a protocol for studying the pathogenesis of E. coli O1:K1:H7, a serotype responsible for high mortality rates in neonates. Our method utilizes intravital imaging of neonatal pups at different time points during the progression of infection. This imaging, paralleled by measurement of bacteria in the blood, inflammatory profiling, and tissue histopathology, signifies a rigorous approach to understanding infection dynamics during sepsis. In the current report, we model two infectious inoculums for comparison of bacterial burdens and severity of disease. We find that subscapular infection leads to disseminated infection by 10 h post-infection. By 24 h, infection of luminescent E. coli was abundant in the blood, lungs, and other peripheral tissues. Expression of inflammatory cytokines in the lungs is significant at 24 h, and this is followed by cellular infiltration and evidence of tissue damage that increases with infectious dose. Intravital imaging does have some limitations. This includes a luminescent signal threshold and some complications that can arise with neonates during anesthesia. Despite some limitations, we find that our infection model offers an insight for understanding longitudinal infection dynamics during neonatal murine sepsis, that has not been thoroughly examined to date. We expect this model can also be adapted to study other critical bacterial infections during early life.

PURPOSE OF REVIEW: The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe’s initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted. RECENT FINDINGS: The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80–95%), the mean time to return to play (typically 12–18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. SUMMARY: The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.

Diffuse actinic keratoses (AKs) have multiple treatment options. Patient understanding of treatment options may enhance patient autonomy, satisfaction, treatment adherence, and clinical outcomes. Delivering effective and consistent verbal counseling on AK treatment can be challenging.We investigated the effect on patient knowledge of implementing, prior to standard counseling, a novel video decision aid explaining diffuse AK treatment options.Participants were recruited from an academic Mohs surgery clinic and randomized to receive the video decision aid plus standard verbal counseling (video) or standard verbal counseling alone (control). Both groups completed baseline, immediate post-intervention, and 1-2 week delayed durable knowledge assessments. Secondary endpoints included participant satisfaction and verbal counseling duration.Thirty-one eligible patients (16 control, 15 video) participated. No baseline differences existed between the groups. The video group had significantly higher mean durable knowledge scores than the controls (video 10.00 ± 1.48, control 8.36 ± 1.69,A video decision aid for treatment of diffuse AKs improved durable patient knowledge.

BACKGROUND AND AIMS: Serotonin (5HT) is a neuroendocrine hormone synthetized in the central nervous system (CNS) as well as enterochromaffin cells of the gastrointestinal tract. Tryptophan hydroxylase (TPH1) and monoamine oxidase (MAO-A) are the key enzymes for the synthesis and catabolism of 5HT, respectively. Previous studies demonstrated that 5-hydroxytryptamine receptor (5HTR)1A/1B receptor agonists inhibit biliary hyperplasia in bile-duct ligated (BDL) rats, whereas 5HTR2B receptor antagonists attenuate liver fibrosis (LF) in mice. Our aim was to evaluate the role of 5HTR2A/2B/2C agonists/antagonists in cholestatic models. APPROACH AND RESULTS: While in vivo studies were performed in BDL rats and the multidrug resistance gene 2 knockout (Mdr2(−/−)) mouse model of PSC, in vitro studies were performed in cell lines of cholangiocytes and hepatic stellate cells (HSCs). 5HTR2A/2B/2C and MAO-A/TPH1 are expressed in cholangiocytes and HSCs from BDL rats and Mdr2(−/−) mice. Ductular reaction, LF, as well as the mRNA expression of proinflammatory genes increased in normal, BDL rats, and Mdr2(−/−) mice following treatment 5HTR2A/2B/2C agonists, but decreased when BDL rats and Mdr2(−/−) mice were treated with 5HTR2A/2B/2C antagonists compared to BDL rats and Mdr2(−/−) mice, respectively. 5HT levels increase in Mdr2(−/−) mice and in PSC human patients compared to their controls and decrease in serum of Mdr2(−/−) mice treated with 5HTR2A/2B/2C antagonists compared to untreated Mdr2(−/−) mice. In vitro, cell lines of murine cholangiocytes and human HSCs express 5HTR2A/2B/2C and MAO-A/TPH1; treatment of these cell lines with 5HTR2A/2B/2C antagonists or TPH1 inhibitor decreased 5HT levels as well as expression of fibrosis and inflammation genes compared to controls. CONCLUSIONS: Modulation of the TPH1/MAO-A/5HT/5HTR2A/2B/2C axis may represent a therapeutic approach for management of cholangiopathies, including PSC.

This chapter reviews the use of Jessner’s peel for the treatment of medical and cosmetic dermatologic conditions. Jessner’s peel is a practical and versatile peel that can be utilized by most any provider and most any skin-type patient. Included in this discussion are the materials and techniques required in the clinical setting to successfully apply this peel. Beyond the practical application, we review the multiple indications as well as the potential contraindications and side effects that each provider and patient should be aware of prior to use. After reading this section, providers should gain knowledge and confidence to utilize this peel alone or in combination to treat a diverse group of patients.

Lower-extremity musculoskeletal injuries are common in sports such as basketball and soccer. Athletes competing in sports of this nature must maneuver in response to the actions of their teammates, opponents, etc. This limits their ability to preplan movements. The purpose of this study was to compare impact accelerations during preplanned versus unplanned lateral cutting. A total of 30 subjects (15 males and 15 females) performed preplanned and unplanned cuts while the authors analyzed impact accelerations using an accelerometer secured to their tibia. For the preplanned condition, subjects were aware of the movement to perform before initiating a trial. For the unplanned condition, subjects initiated their movement and then reacted to the illumination of one of 3 visual stimuli which dictated whether they would cut, land, or land-and-jump. A mixed-model analysis of variance with a between factor of sex (male and female) and a within factor of condition (preplanned and unplanned) was used to analyze the magnitude and variability of the impact accelerations for the cutting trials. Both males and females demonstrated higher impact accelerations (P = .01) and a trend toward greater intertrial variability (P = .07) for the unplanned cutting trials (vs preplanned cuts). Unplanned cutting may place greater demands on the musculoskeletal system.

BACKGROUND: The natural history of post-injury among elderly trauma patients has not been well described. We hypothesized that elderly trauma patients would have lower admission hemoglobin (Hb) levels, higher transfusion rates, and worse outcomes than young trauma patients. METHODS: We performed a propensity-matched retrospective cohort analysis comparing elderly (age ≥65 years) to young (age 18–64) trauma patients matched by sex, mechanism of injury, Injury Severity Score, base deficit, comorbidities, operative blood loss, and phlebotomy blood loss (n=41/group). Outcomes included Hb trends, packed red blood cell (PRBC) transfusion, length of stay, and mortality. RESULTS: Elderly patients had lower admission Hb (11.3 vs. 10.2 g/dL, p=0.012), received more PRBC transfusions within 24 hours (3.6 vs. 1.8 units, p=0.046) and during admission (6.9 vs. 4.3 units, p=0.008). Despite receiving more PRBC transfusions and having similar operative and phlebotomy blood loss, elderly subjects had lower discharge Hb (9.0 vs. 9.7 g/dL, p=0.013). Elderly subjects had fewer ICU-free days (2.0 vs. 6.0 days, p

The dense formation of abnormal scar tissue after total knee arthroplasty results in arthrofibrosis, an unfortunate sequela of inflammation. The purpose of this study was to use a validated rabbit model to assess the effects on surgically-induced knee joint contractures of two combined pharmacological interventions: celecoxib (CXB) loaded on an implanted collagen membrane, and subcutaneously (SQ) injected ketotifen. Thirty rabbits were randomly divided into five groups. The first group received no intervention after the index surgery. The remaining four groups underwent intra-articular implantation of collagen membranes loaded with or without CXB at the time of the index surgery; two of which were also treated with SQ ketotifen. Biomechanical joint contracture data were collected at 8, 10, 16, and 24 weeks. At the time of necropsy (24 weeks), posterior capsule tissue was collected for messenger RNA and histopathologic analyses. At 24 weeks, there was a statistically significant increase in passive extension among rabbits in all groups treated with CXB and/or ketotifen compared to those in the contracture control group. There was a statistically significant decrease in COL3A1, COL6A1, and ACTA2 gene expression in the treatment groups compared to the contracture control group (P < .001). Histopathologic data also demonstrated a trend towards decreased fibrous tissue density in the CXB membrane group compared to the vehicle membrane group. The present data suggest that intra-articular placement of a treated collagen membrane blunts the severity of contracture development in a rabbit model of arthrofibrosis, and that ketotifen and CXB may independently contribute to the prevention of arthrofibrosis. Statement of clinical significance: Current literature has demonstrated that arthrofibrosis may affect up to 5% of primary total knee arthroplasty patients. For that reason, novel pharmacologic prophylaxis and treatment modalities are critical to mitigating reoperations and revisions while improving the quality of life for patients with this debilitating condition.

Background: Research has shown disparities between provision of bystander CPR among different race, gender and age groups. Reasons for this disparity have included concern of legal liability by responders. We propose that bystanders are more likely to face litigation for lack of intervention as opposed to providing bystander CPR. This review of the legal literature seeks to quantify the number of cases brought against responders in the USA over the past 30 years. Methods: The Westlaw legal research database was searched for jury verdicts, settlements, and appellate opinions from all 50 states from 1989 to 2019, in which the use or non-use of CPR gave rise to a personal injury or wrongful death lawsuit. A total of 274 cases were initially identified and manually reviewed. Outcomes recorded included case jurisdiction, location, date, plaintiff and defendant demographics, bystander training, motivation for the lawsuit, including claims of battery for performing CPR or negligence related to injuries or death following CPR or AED use. Results: Preliminary data shows that 41.1% (114 of 274) of all cases screened were directly due to the provision of bystander CPR or lack thereof. Among the relevant cases, 64% (73 of 114) were due to inadequate or untimely bystander CPR. Battery cases due to providing CPR amounted to 32% (32 of 114), but of these, 59.4% (19 of 32) were ruled in favor of the defendant. Conclusions: This represents the largest study of legal cases involving bystander CPR in the medical literature, limitations include a lack of a national repository of trial data thus underestimating the total number of cases involving bystander CPR. The likelihood of facing litigation is significantly higher in cases where bystander CPR was delayed or not provided. The authors propose the inclusion of this data and reiteration of protective statutes in all 50 states during CPR training to reassure and encourage trainees.

Purpose: Patients of substance use disorder (SUD), who successfully complete the treatment programs recommended by their therapists, have better health outcomes than the vast majority who drop out in the middle. We investigated the contribution of race and gender of both patients and therapists to address the cause of treatment noncompletion and gaps in knowledge. Method: Data collected from 11 SUD treatment outpatient programs, comprising 2,230 patients and 69 therapists, were analyzed to understand the effect of therapist–patient profile matching on treatment completion success rate. Results: Of the overall completion rate of 23%, White-male therapists had the highest rate (ranging from 20.4% to 50.0%) followed by White-female therapists (13.9% and 31.2%) dependent on patients’ race or gender. Non-White female and male therapists alike had varied but lesser completion rate. Discussion: Our studies recommend research and practice implementing performance-based practice measures with appropriate patient–therapist matching for better SUD-treatment outcomes.