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Around the world, water rights systems govern the allocation of water to a multitude of users. Such systems primarily come into play during times of drought, when some users have to be shorted. Yet their management during times of excess can have implications for subsequent drought impacts. This is evident in the State of Colorado, where under "free river conditions" in which there is sufficient water to satisfy all water rights, anyone—including individuals lacking water rights—can divert as much as they want, unconstrained by the limit of their water right. Here, we estimate the amount of excess water used under such conditions within Division five of the Upper Colorado River Basin in the State of Colorado. Comparing the daily water withdrawals of diversion structures along the Colorado River and its tributaries with their (daily) water rights, we find that in 2017, 339 structures report days with excess withdrawals, amounting to 108 million cubic meters (87,577 acer feet). While such excess withdrawal is legal in Colorado, we argue that the free river condition is an antiquated rule that will make much needed reform of water allocation within the water‐stressed Colorado River Basin more difficult. We offer policy suggestions to address it. Plain Language Summary: Challenging water stress situations can be catalysts for reform. The Colorado River Basin is facing such a situation with ongoing drought since the turn of the Century. In the absence of much willingness for change, we propose a pragmatic step toward reform. Within the State of Colorado, when all water users have sufficient water to meet their decreed volumetric water right, the river is said to be in "free river conditions." Under these conditions, anyone—whether or not they own a water right—can divert as much water as they'd like until a senior user downstream makes a "call" on the river because they no longer have enough water to satisfy their right. We estimate that under free river conditions, excess water withdrawals of 108 million cubic meters (87,577 acer feet) is diverted beyond water users' decreed volumetric rights. We argue that such improperly defined water rights stand in the way of longer‐run reforms that seek to bring demand and supply in line in the Colorado River Basin, and propose alternative policies to bank this water to stave off future droughts. Key Points: We quantify the excess water diversions in the Upper Colorado Basin that go beyond diverters' water rightsThe Excess Diversions are a loophole in the Colorado Water System that will impede reformsStemming the Excess diversions will potentially help reduce economic and ecological stress of further depletion of Lake Powell [ABSTRACT FROM AUTHOR]

Background: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates., Methods: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused., Results: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) ( P  = .0085). Multivariable regression demonstrated that autograft use was independent associated with union ( P  = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion ( P  = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) ( P   ≤  .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types., Conclusion: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques., Level of Evidence: Level III, therapeutic., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Todd A. Irwin, MD, reports royalties or licenses and consulting fees from Paragon 28 and MEDLINE. Bruce E. Cohen, MD, reports royalties or licenses and consulting fees from Stryker. J. Kent Ellington, MD, reports royalties or licenses from Synthes, Stryker, and MEDLINE, and consulting fees from Stryker and MEDLINE. Carroll P. Jones III, MD, reports royalties or licenses and consulting fees from Stryker (EasyFuse Staples). Scott B. Shawen, MD, reports royalties or licenses; consulting fees; and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from CrossRoads Extremities, Synthes, J&J; Medline Industries; and patents planned, issued, or pending from CrossRoads Extremities. Samuel E. Ford, MD, reports consulting fees from Stryker. Disclosure forms for all authors are available online.

Study Design: Randomized controlled trial (RCT)., Objective: Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures., Summary of Background Data: Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures., Methods: This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC)., Results: Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively., Conclusions: A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the impact of geodemographic factors on antibiotic prescribing for adult acute, uncomplicated bronchitis or upper respiratory tract infection., Methods: A retrospective, observational study of 63,051 single health-system, outpatient discharges with a primary diagnosis of bronchitis or upper respiratory tract infection in 2019. Univariate analyses of prescribing predictors and multivariable stepwise logistic modeling were performed., Results: Patients who were older (aOR 1.02; 95% CI 1.02, 1.02), male (1.10; 1.06, 1.14), black (1.29; 1.22, 1.38), smoked (1.18; 1.14, 1.23), seen in urgent care (1.26; 1.22, 1.31) and living in an area with more owner-occupied housing (1.41; 1.30, 1.53) were more likely to receive antibiotics. Patients who were Asian (0.88; 0.77, 0.99), had Medicare (0.83; 0.78, 0.87), Medicaid (0.84; 0.79, 0.87) or Exchange insurance (0.90; 0.82, 0.98), or seen in the emergency department (0.43; 0.40, 0.46) were less likely to receive antibiotics. Distance from a patient's address and their encounter location did not predict antibiotic prescribing., Conclusions: Antibiotic prescribing interventions for adult acute bronchitis and upper respiratory tract infections could target patients living in an area with higher socioeconomic status., Competing Interests: Conflicts of interest: None., (© Copyright 2022 by the American Board of Family Medicine.)