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Complex abdominal wall hernias represent a significant reconstructive challenge to the general surgeon. In patients with loss of abdominal domain, standard surgical techniques such as anterior component separation or transversus abdominus muscle release may not allow for primary fascial closure. In complex ventral wall hernias, visceroabdominal disproportion may need to be addressed prior to an attempt at hernia repair. Tissue expanders placed in the intermuscular space is a novel technique used to increase intraabdominal volume and safely allow reduction of viscera with subsequent closure of the myofascia. We present the case of an adult patient with complications of an untreated congenital omphalocele who underwent a successful two stage operation using tissue expanders in the abdominal wall combined with anterior component separation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Primrose, McClaren and Slater.)

Background: Overdose remains a pressing public health concern in the United States, particularly with the emergence of fentanyl and other potent synthetic opioids in the drug supply. We evaluated trends in recurrent overdose and opioid use disorder (OUD) treatment initiation following emergency department (ED) visits for opioid overdose to inform response efforts., Methods: This retrospective cohort study used electronic health record and statewide administrative data from Rhode Island residents who visited EDs for opioid overdose between July 1, 2016, and June 30, 2021, a period with fentanyl predominance in the local drug supply. The primary outcome was recurrent overdose in the 365 days following the initial ED visit. OUD treatment initiation within 180 days following the initial ED visit was considered as a secondary outcome. Trends in study outcomes were summarized by year of the initial ED visit., Results: Among 1745 patients attending EDs for opioid overdose, 20 % (n=352) experienced a recurrent overdose within 365 days, and this percentage was similar by year (p=0.12). Among patients who experienced any recurrent overdose, the median time to first recurrent overdose was 88 days (interquartile range=23-208), with 85 % (n=299/352) being non-fatal. Among patients not engaged in OUD treatment at their initial ED visit, 33 % (n=448/1370) initiated treatment within 180 days; this was similar by year (p=0.98)., Conclusions: Following ED visits for opioid overdose in Rhode Island from 2016-2021, the one-year risk of recurrent overdose and six-month treatment initiation rate remained stable over time. Innovative prevention strategies and improved treatment access are needed., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest., (Copyright © 2024. Published by Elsevier B.V.)

Context: In the United States, minority populations are disproportionately affected by the overdose epidemic, have higher mortality rates, and unequal access to harm reduction and treatment services., Objective: This analysis aims to better understand harm reduction utilization and substance use patterns among minority populations to improve overdose outreach and prevention initiatives in Rhode Island., Design: The present analysis used data from the Harm Reduction Surveillance System from January 2021 to December 2022 (N = 393). Chi-square tests and multivariable regression models were used to investigate differences in substance use behaviors by race and ethnicity., Setting: Rhode Island., Participants: Participants include individuals who self-reported the use of illicit drugs, currently reside in Rhode Island, and were older than 18 years., Main Outcome Measures: Methods of drug use and uptake of harm reduction practices., Results: Among survey participants, 41% were non-Hispanic White, 57% were aged 25 to 44 years, 62% identified as male, and 95% had health insurance coverage. Most participants reported smoking as their method of drug use (90%) and harm reduction practices were underutilized by all race and ethnicity groups. Fewer non-Hispanic Black participants reported carrying naloxone compared to the other race and ethnicity groups. Non-Hispanic Black and Hispanic participants were significantly less likely to inject drugs compared with non-Hispanic White participants (adjusted odds ratio [AOR] = 0.14; 95% confidence interval [CI], 0.04-0.45) (AOR = 0.40; 95% CI, 0.18-0.90)., Conclusions: Smoking was the most common self-reported method of substance administration for all participants, whereas injection was more prevalent among non-Hispanic White participants. There is a continued need for minority-led and culturally informed harm reduction and treatment services for minority populations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Over the last 21 years, drug overdose deaths have increased nationwide, particularly in Rhode Island (RI). The goal of this work is to identify populations that are disproportionately impacted by accidental drug overdose deaths to guide future intervention efforts.  Methods: We obtained data on accidental and undetermined drug overdose deaths from the RI State Unintentional Drug Overdose Reporting System (SUDORS) database from 2016 to 2021. We compared basic demographic factors stratified by decedent race and ethnicity. Chi Square and Fisher's exact tests were used to determine differences in characteristics across racial groups., Findings: Across all race and ethnic groups, cocaine-involved (64.5%) fatal overdoses were higher among Black non-Hispanics. White, non-Hispanics (31.4%) were more likely to receive treatment for substance use disorder (SUD) when compared to minority groups., Conclusion: To help address the gaps in treatment for SUD among minority groups, culturally responsive intervention efforts should prioritize connecting minority groups to treatment.

Background: American Indians have the highest prevalence of type 2 diabetes compared with any other racial or ethnic group., Objective: Developing a culturally tailored diabetes prevention and management intervention is one way to reduce diabetes-related health disparities among American Indian populations. The purpose of this article is to describe our approach for developing a diabetes prevention and management intervention study using Kolb's Experiential Learning Theory as the framework., Methods: To ensure the intervention study was culturally meaningful and relevant we used community-based participatory principles by partnering with a team of nurse researchers, tribal diabetes educators, tribal leaders, and tribal community members who were involved in all aspects of the study process. We conducted seven focus groups predominantly in rural American Indian communities in Oklahoma. Using focus group findings, the team collaboratively designed and developed a multi-generational diabetes prevention and management intervention study. The intervention group sessions will focus on ways to prevent and manage diabetes while the control group sessions will focus on general health education topics that have been identified by the team as important and relevant., Conclusions: Family interventions that involve multiple generations and provide emotional and behavioral support to those with type 2 diabetes and family members at risk may provide our best chance at improving diabetes-related outcomes and reducing health disparities in this critical population.

Religiosity may influence COVID-19 vaccination. However, it remains unclear how religiosity is associated with beliefs toward COVID-19 and vaccination against it, particularly amongst ethnic minorities. This study examined the association between religiosity, vaccination intent, beliefs, and attitudes related to COVID-19 and vaccination among adults in Puerto Rico. Data from an online survey conducted between December 2020-February 2021 among adults (≥18 yr; n = 1895) residing in Puerto Rico were used. Rating of the importance of religiosity was used to capture the level of religiosity ('less important', 'somewhat important', 'important', and 'very important'). The health belief model (HBM) assessed beliefs and attitudes toward COVID-19 and vaccination against it. Adjusted Poisson models with robust error variance estimated prevalence ratios (PR) and 95% confidence intervals for vaccination intent and individual COVID-19 HBM constructs. Compared to individuals rating religiosity as 'less important' to them, those rating it as 'very important' were more likely to be unwilling or uncertain to get the COVID-19 vaccine (PR = 1.51, 95% CI = 1.10-2.05). Higher ratings of importance of religiosity, compared to the lowest level, were associated with significantly lower perceived COVID-19 susceptibility, more vaccine barriers, and lower vaccine benefits (all p < 0.05). Individuals who reported religiosity being very important to them were more likely to report that they will get the COVID-19 vaccine only if given adequate information about it (PR = 1.14, 95% CI = 1.02-1.27) and more likely to get the vaccine if more people decide to receive it (all p < 0.05). In conclusion, our results suggest an association between religiosity and COVID-19 vaccination intent and beliefs and attitudes toward vaccination. The study highlights important guidelines for public health campaigns to increase vaccine uptake among religious communities in Puerto Rico.

Ethnic minority populations are more likely to suffer from chronic comorbidities, making them more susceptible to the poor health outcomes associated with COVID-19 infection. Therefore, ensuring COVID-19 vaccination among vulnerable populations is of utmost importance. We aimed to investigate health behaviors and perceptions of COVID-19 vaccination among adults self-reporting diagnosis of cancer and of other chronic comorbidities in Puerto Rico (PR). This secondary analysis used data from 1911 participants who completed an online survey from December 2020 to February 2021. The Health Belief Model was used to measure perceptions surrounding COVID-19 vaccination among individuals self-reporting diagnosis of cancer and of other chronic comorbidities, and healthy adults. Among study participants, 76% were female, 34% were 50 years or older, 5% self-reported cancer diagnosis, and 70% had other chronic comorbidities. Participants self-reporting a cancer diagnosis had two times higher odds of getting vaccinated than healthy individuals (95% CI: 1.00-4.30). Compared to healthy participants, those self-reporting being diagnosed with cancer and those with chronic conditions other than cancer had significantly higher perceived COVID-19 susceptibility and severity. Our findings elucidate the effect of disease status on health-related decision-making and highlights information needed to be included in education campaigns to increase vaccine uptake among ethnic minority populations.

Background: Current soft tissue fillers are a compromise between ease of use, duration of correction, reactivity, and cost. A product utilizing calcium hydroxylapatite (CaHA) is currently being used as a soft tissue filler., Objective: The objective was to compare the efficacy and safety of CaHA microspheres versus human-based collagen for the correction of nasolabial folds., Materials and Methods: Four centers enrolled 117 subjects with moderate to deep nasolabial folds. Subjects received CaHA on one side of the face and human collagen on the other. Up to two touch-ups were allowed. A blinded panel of experts evaluated subject photographs from initial and follow-up visits., Results: Seventy-nine percent of subjects had superior improvement on the CaHA side through 6 months (p<.0001). For optimal correction, significantly less volume and fewer injections were needed for CaHA than for collagen (p<.0001). Adverse event rates were comparable, with some increase in bruising and edema for CaHA-treated sides. Adverse event duration was similar for both groups and generally resolved within 14 to 21 days., Conclusion: This CaHA-based product gives significantly longer-lasting correction of nasolabial folds compared to human collagen. Less total material and fewer injections are required. The adverse event profile of the product is similar to the collagen-based product.

Background: Sebaceous hyperplasia is a benign proliferation of the sebaceous gland. Previous treatment options have included isotretinoin, destructive modalities, and pulsed-dye laser., Objective: To evaluate the efficacy of a 1450-nm diode laser for the treatment of sebaceous hyperplasia., Methods: Ten patients with sebaceous hyperplasia were treated one to five times with a 1450-nm diode laser. Fluences of 16 to 17 J/cm2 were used, with cooling durations of 40 to 50 ms. Patients and physicians evaluated treated lesions for improvement. Measured areas of treated lesions were also recorded., Results: In most cases, patients and physicians rated improvement as "very good" or better. After two to three treatments, 84% of lesions shrunk greater than 50%, and 70% shrunk greater than 75%. Adverse effects were unusual; one atrophic scar and one case of transient hyperpigmentation were observed., Conclusion: The 1450-nm diode laser is effective and safe for the treatment of sebaceous hyperplasia.

Background: Laser resurfacing has become a popular modality for the treatment of photodamaged skin, rhytids, and acne scarring. In many cases, this procedure is performed under general anesthesia or intravenous sedation in conjunction with nerve blocks and local infiltration., Objective: To evaluate the safety and efficacy of facial carbon dioxide laser resurfacing using a supplemented topical anesthesia protocol., Design: Nonrandomized case series of patients observed for 1 year., Setting: Outpatient surgery center., Patients: Two hundred consecutive patients undergoing treatment for facial rhytids or acne scarring. Intervention Full-face carbon dioxide laser resurfacing procedures were performed using a supplemented topical anesthesia protocol. Pretreatment medications included diazepam, oral analgesics, and intramuscular ketorolac tromethamine., Main Outcome Measures: Tolerability of procedure, healing times, and adverse effects., Results: Topical anesthesia provided effective and sufficient anesthesia in most cases. Only 10 of 200 patients required additional anesthesia (regional nerve blocks and/or local infiltration). Substantial improvement of rhytids, photodamage, and acne scarring was observed. Posttreatment hypopigmentation was seen in 1 patient. Scarring was not observed. Conclusion A supplemented topical anesthesia protocol for full-face laser resurfacing is a safe and effective alternative to traditional anesthesia strategies.

Although competence to stand trial is perhaps the most studied area of mental health law, most of the research has been focused on adults. This study describes a population of 471 juveniles committed for treatment/habilitation and restoration of their competence to proceed in the delinquency process. This population differed from their adult counterparts in important ways. For example, 58 percent of the juveniles had a diagnosis of mental retardation, and 57 percent of the juveniles with an Axis I diagnosis also had a diagnosis of conduct disorder. Only 17 percent had a diagnosed psychotic disorder. Diagnoses among cohorts of adults found incompetent differ markedly. However, similar to adult defendants who are adjudicated incompetent to proceed, the majority of these children were returned to court after treatment staff determined that they were competent to proceed. Contrary to expectation, there were no significant age-related differences with respect to the recommendation of clinical staff regarding restoration of competence. The data suggest the need for further research examining that subset of children in the juvenile justice system whose competence to proceed is questionable.

Exposure of human keratinocytes to environmental stress is known to induce changes in the expression, phosphorylation, and subcellular relocalization of the 27 kDa heat shock protein. This study demonstrates that ultraviolet B (280-320 nM) irradiation with physiologic doses induces a dose-dependent phosphorylation of 27 kDa heat shock protein, generating the more acidic 27 kDa heat shock protein B, C, and D isoforms. Ultraviolet B also induces perinuclear cytoplasmic relocation and nuclear translocation of 27 kDa heat shock protein and caused aggregation of cytoplasmic actin filaments into a broad perinuclear distribution. The ultraviolet B-induced phosphorylation is reversible, returning to baseline levels 4 h after exposure, and this coincides with the reversal of ultraviolet B-induced actin reorganization. The ultraviolet B-induced phosphorylation is not affected by the protein kinase C inhibitor, GF 109203X, is partially inhibited by epidermal growth factor receptor tyrosine kinase inhibitor, PD 153035, and is substantially inhibited by the specific p38 mitogen-activated protein kinase inhibitor, SB 203580. In addition, pretreatment of cells with the anti-oxidant N-acetyl cysteine partially inhibits ultraviolet B-and oxidant-induced 27 kDa heat shock protein phosphorylation. The p38 mitogen-activated protein kinase cascade is thus the major transduction pathway for ultraviolet B-induced 27 kDa heat shock protein phosphorylation, and reactive oxygen species generated in response to ultraviolet B also contribute to this phosphorylation. As 27 kDa heat shock protein phosphorylation and relocalization has been associated with increased cell survival after environmental insult, our data suggest that ultraviolet B, in addition to initiating recognized cytotoxic events in keratinocytes, also initiates a signaling pathway that may provide cellular protection against this ubiquitous environmental insult.

Stress proteins, which are found ubiquitously in mammalian cells, appear to be implicated in the regulation of cell growth and protection from environmental insult. Although we previously demonstrated the expression of low-molecular-weight stress protein, HSP 27, in cultured keratinocytes, HSP 27 has not yet been identified in human skin. Using standard immunohistochemistry on routinely processed paraffin sections, we examined specimens of common epidermal lesions and normal skin with a monoclonal antibody to HSP 27. Normal skin from the breast, foreskin, and lower extremity demonstrated strong cytoplasmic staining in the suprabasal epidermis. There was no change in the intensity of staining or cellular localization related to age, body location, or gender. Sections of actinic keratosis, superficial basal cell carcinoma, seborrheic keratosis, and psoriasis also exhibited strong cytoplasmic staining in the suprabasal layers of the epidermis. In contrast, cutaneous squamous cell carcinoma demonstrated only weak cytoplasmic staining throughout the infiltrating tumor. This is of particular interest, since other investigators have reported a loss of HSP 27 expression in oncogenically transformed cells that exhibit a tumorigenic phenotype. To our knowledge, this study provides the first demonstration of HSP 27 expression in human skin.

We have begun to characterize the low molecular weight, 27-kD heat shock or stress protein (HSP27) in normal keratinocytes and in HaCaT, a spontaneously transformed keratinocyte line. The presence and location of HSP27 was determined by indirect immunofluorescence on fixed whole cells and immunoblot analysis of cytosolic, membrane, nuclear, and cytoskeletal cell fractions. HSP27 is localized throughout the cytoplasm of cells at 37 degrees C. After heating at 42 degrees C, there is a rapid (within 10 min) increase in nuclear HSP27. Two-dimensional gel analysis of whole cell HaCaT lysates identified multiple isoforms of HSP27 with different isoelectric points. The function of HSP27 is largely unknown but its presence throughout the cytoplasm of cells at 37 degrees C, its translocation to the nucleus after cellular stress, and the presence of multiple isoforms suggest a biologic role in both stressed and unstressed human keratinocytes.