Descriptive study: the novel "full spectrum people-with-opioid-use-disorder care model".

BACKGROUND: People with Opioid Use Disorder (PWOUD) represent an underserved and marginalized population for whom treatment gaps exist. Low-barrier programs like mobile care units and street outreach programs have yielded increased access to buprenorphine and social services, however, OUD pertinent co-occurring behavioral health and medical conditions are frequently left unaddressed. A novel, tailored, comprehensive care delivery model may reduce disparities and improve access to care across a range of pathologies in this historically difficult to reach population and enhance efforts to provide universal treatment access in a harm reduction setting. METHODS: Descriptive data were collected and analyzed regarding patient demographics, retention in treatment and services rendered at a new, wrap-around, low-barrier buprenorphine clinic established at an existing harm reduction site in New Mexico between August 1, 2020, and August 31, 2021. RESULTS: 203 people used any service at the newly implemented program, 137 of whom specifically obtained medical and/or behavioral health care services including prescriptions for buprenorphine at least once from the physician onsite. Thirty-seven unique medical and psychiatric conditions were treated, representing a total of 565 separate encounters. The most common service utilized was buprenorphine treatment for opioid use disorder (81%), followed by treatment for post-traumatic stress disorder (62%), anxiety (44.5%) and depression (40.9%). Retention in buprenorphine treatment was 31.2% at 6 months. CONCLUSIONS: An innovative, multidisciplinary, buprenorphine-centric care model, which targets a wide range of OUD pertinent pathologies while employing a harm reduction approach, can enhance utilization of these services among an underserved PWOUD population in a manner which moves our health system toward universal OUD treatment access thereby potentially reducing overdose and existing disparities.

Re-visiting Drain Use in Operative Liver Trauma: A Retrospective Analysis.

BACKGROUND: Despite the liver being one of the most frequently injured abdominal organs in trauma patients, clinical management strategies differ between trauma surgeons. Few studies have critically evaluated current practice patterns in the operative management of liver trauma. Historical studies recommended against the use of drains but there has not been a modern investigation of this issue. The objective of this study was to analyze outcomes associated with intra-operative drain use for liver trauma. METHODS: A retrospective chart review of all adult trauma patients presenting to a Level I trauma center from 2012 to 2018 was performed. Patients who underwent operative management of liver trauma were divided into groups based on whether an intra-abdominal drain was utilized and differences in outcomes between the groups were analyzed. The primary endpoint evaluated was post-operative intra-abdominal abscesses. Univariate and multivariate analyses were performed. RESULTS: 184 patients with operative management of liver trauma were included in the study. Closed suction drains were utilized in 26.1% of post-operative patients. Rate of intra-abdominal abscesses was significantly higher in the drain group (35.4% versus 8.8%, P < 0.001). Drains were more commonly used in patients receiving more units of PRBCs (median, 9 units [IQR 4-20] versus median 5.5 units, [IQR 2-14], P = 0.03). Drain use was found to be an independent risk factor for post-operative intra-abdominal abscess on multivariate analysis (OR 4.9, 95% CI 1.7-14, P = 0.003). CONCLUSIONS: The results of this study support previous conclusions that drain placement for operative liver trauma is associated with increased risks of infectious complications. Drains were used in patients with more severe liver injury, intra-operative bile leaks, penetrating trauma, and increased blood transfusion requirements. Future studies should focus on the development of specific guidelines for the use of drains in liver trauma.

Is the "Death Triad" a Casualty of Modern Damage Control Resuscitation.

BACKGROUND: Principles of damage control laparotomy (DCL) focus on early surgical control of hemorrhage and contamination in addition to damage control resuscitation (DCR) to combat the significant mortality associated with the "death triad" of hypothermia, acidosis, and coagulopathy. We hypothesized that DCL patients managed with DCR would have lower mortality from the death triad than historical studies. METHODS: A 5-y retrospective chart review of all consecutive adult trauma patients presenting to a Level I trauma center who underwent DCL was conducted. Parameters associated with the death triad were evaluated on admission and 24 h after the presentation. Kaplan Meier survival plots were used to compare the components of the death triad. Univariate and multivariate analyses were performed. RESULTS: A total of 149 adult patients were identified. The overall incidence of death triad was 20.8% (n = 31/149). 24-h mortality for all patients was 5.4% (n = 8/149). Kaplan Meier plots showed that 24-h mortality was significantly increased if 3/3 components of the death triad were present (P < 0.05). At 24-h after admission, mortality occurred in 16.6% (n = 5/30) of patients with the death triad. CONCLUSIONS: This study confirms that the 24-h mortality of trauma patients increased with the addition of all three death triad components. The death triad predicted death in 16.6% of patients treated with DCL and DCR at 24 h. Results suggest that the death triad might not be as applicable in the modern era of DCL in combination with DCR. Other factors contributing to in-hospital mortality need to be further elucidated.

Should Surgery Residents Receive Pre-operative Skin Preparation Training: An Association of Program Directors in Surgery Survey.

PURPOSE: Surgical site infections (SSI) are a significant source of peri-operative morbidity and a financial burden on the healthcare system. Effective pre-operative skin preparation has been shown to reduce SSI incidence, however studies demonstrated that most healthcare providers do not adhere to proper techniques. Skin prep technique is not taught to U.S. surgical residents in a standardized format. The objective of this study was to perform a survey of U.S. surgical training programs to determine the practice patterns of surgical resident education on the proper techniques of pre-operative antiseptic surgical prep. METHODS: An 18-question anonymous survey was created using the Qualtrics platform. The survey was distributed to members of the Association of Program Directors in Surgery listserv over a 2-month period. Responses were compiled and data analysis was performed. RESULTS: The survey response rate was 30% (n = 85/280). 81% of respondents reported that surgery residents are responsible for performing pre-operative skin prep at their institutions. The same proportion (81%) reported that they feel surgical skin prep techniques are an important component of surgical resident education. However, only 42% reported that their residents are provided formal education regarding proper skin prep techniques and only 6% reported that their residents are required to take a written or practical proficiency exam. 42% of respondents felt that formal skin prep education for residents is likely to affect the rate of surgical site infections. CONCLUSIONS: Surgical residents commonly perform pre-operative skin preparation. However, few residents receive formal education or evaluation of these skills. Given the importance of pre-operative skin preparation in reducing SSIs and the potential for patient harm if performed incorrectly, the results from this study raise the question of whether formal surgical resident education regarding pre-op skin prep should be more widely adopted and standardized.

Initial Experience With Biologic Polymer Scaffold (Poly-4-hydroxybuturate) in Complex Abdominal Wall Reconstruction.

OBJECTIVE: To evaluate the use of the new absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) in complex abdominal wall reconstruction. BACKGROUND: Complex abdominal wall reconstruction has witnessed tremendous success in the last decade after the introduction of cadaveric biologic scaffolds. However, the use of cadaveric biologic mesh has been expensive and plagued by complications such as seroma, infection, and recurrent hernia. Despite widespread application of cadaveric biologic mesh, little data exist on the superiority of these materials in the setting of high-risk wounds in patients. P4HB, an absorbable polymer scaffold, may present a new alternative to these cadaveric biologic grafts. METHODS: A retrospective analysis of our initial experience with the absorbable polymer scaffold P4HB compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our analysis was performed using SAS 9.3 and Stata 12. RESULTS: The P4HB group (n = 31) experienced shorter drain time (10.0 vs 14.3 d; P < 0.002), fewer complications (22.6% vs 40.5%; P < 0.046), and reherniation (6.5% vs 23.8%; P < 0.049) than the porcine cadaveric mesh group (n = 42). Multivariate analysis for infection identified: porcine cadaveric mesh odds ratio 2.82, length of stay odds ratio 1.11; complications: drinker odds ratio 6.52, porcine cadaveric mesh odds ratio 4.03, African American odds ratio 3.08, length of stay odds ratio 1.11; and hernia recurrence: porcine cadaveric mesh odds ratio 5.18, drinker odds ratio 3.62, African American odds ratio 0.24. Cost analysis identified that P4HB had a $7328.91 financial advantage in initial hospitalization and $2241.17 in the 90-day postdischarge global period resulting in $9570.07 per case advantage over porcine cadaveric mesh. CONCLUSIONS: In our early clinical experience with the absorbable polymer matrix scaffold P4HB, it seemed to provide superior clinical performance and value-based benefit compared with porcine cadaveric biologic mesh.

Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical analgesia in robotic laparoscopic prostatectomy: a pilot study.

BACKGROUND: Transversus abdominis plane (TAP) infiltration has been increasingly used for postsurgical analgesia in abdominal/pelvic procedures; however, duration/extent of analgesia with standard local anesthetics is limited. This pilot study assessed the preliminary efficacy and safety of two volumes of liposome bupivacaine administered via TAP infiltration in patients undergoing robotic laparoscopic prostatectomy. METHODS: In this single-center, open-label, prospective study, patients older than 18 years received TAP infiltration with liposome bupivacaine immediately after surgery. The first 12 patients received a total volume of 20 mL liposome bupivacaine (266 mg); the next 12 received 40 mL liposome bupivacaine (266 mg). The liposome bupivacaine was diluted with 0.9% normal saline. The primary efficacy measure was duration of analgesia, measured by time to first opioid administration. Secondary outcome measures included patient-assessed pain scores, opioid use, and opioid-related adverse events (AEs). RESULTS: Twenty-four patients received liposome bupivacaine (20 mL, n=12; 40 mL, n=12) and were included in the primary analysis. Three refused participation in a 10-day follow-up visit and did not complete the study. Median time to first opioid administration after surgery was 23 and 26 minutes for the 20 and 40 mL groups, respectively. Mean total amount of postsurgical opioids ranged from 25.4 to 27.3 mg; after hospital discharge to day 10, both groups required a mean of 0.7 oxycodone/acetaminophen tablets/day. Mean pain scores of 4.4 and 5.3 were reported at 1 hour and 3.1 and 3.9 at 2 hours postsurgery, with 20 and 40 mL doses, respectively. Neither group had mean scores higher than 3.0 at any further assessments. No opioid-related or treatment-related serious AEs were reported. CONCLUSION: Median time to first opioid administration did not differ between the two groups. No differences in secondary outcomes were observed on the basis of volume administered. These initial findings suggest further study of liposome bupivacaine administered via TAP infiltration as part of a multimodal analgesic regimen in laparoscopic robotic prostatectomy may be warranted.

Causality assessment of drug-induced hepatotoxicity: promises and pitfalls.

Drug-induced liver injury is the leading cause of acute liver failure in the United States, but the ability to ascribe hepatic injury confidently to a specific drug remains a challenging and often difficult pursuit. This article explores the ongoing challenges inherent in what is currently a clinical process of elimination made in the attempt of assigning causality in drug-induced liver injury. In particular, it points out the shortcomings and pitfalls that often limit the applicability of the causality-assessment methodologies currently in use.

Testing of CpG-optimized protein and DNA vaccines against the hepatitis B virus in chimpanzees for immunogenicity and protection from challenge.

Despite the existence for some time of effective prophylactic vaccines, hepatitis B virus (HBV) infection remains an important global concern. Improvements on existing vaccines could be beneficial, especially in situations where it is desirable or necessary to induce protective immunity more rapidly or with fewer doses. We have compared, in chimpanzees, a current HBV vaccine that contains recombinant hepatitis B surface antigen HBsAg) adsorbed to alum, with two novel vaccine strategies that have proven superior to the current vaccine in mice. The first approach was the use of oligodeoxynucleotides containing CpG motifs (CpG ODN) as an adjuvant to Engerix-B, a commercial HBV vaccine. The addition of CpG ODN to Engerix-B greatly improved the kinetics and magnitude of the humoral response, suggesting that CpG ODN might allow induction of protective immunity in humans more quickly and with fewer vaccine doses. All animals receiving either control or CpG-containing subunit vaccines at 0 and 4 weeks attained titers of HBsAg-specific antibody (anti-HBs) considered protective (> or =10 mIU/ml) and were indeed protected from challenge at 8 weeks with 10(3.5) 50% chimp infectious doses (CID(50)) of intravenous HBV. The second approach was a DNA vaccine with a plasmid vector optimized for content of immunostimulatory CpG motifs. Despite the fact that earlier studies had shown four doses of a similar DNA vaccine (except not optimized for CpG content) to induce strong humoral responses in 1 of 2 chimpanzees, in this study two doses of DNA vaccine (at 0 and 4 weeks) did not generate any detectable anti-HBs in either of 2 chimpanzees, although it did protect 1 that rapidly developed anti-HBs during the incubation period, suggesting priming of an antibody response. The poor results may be due to an inadequate number of doses or amount of plasmid DNA in these larger animals, but nevertheless point to the need to improve delivery methods for DNA vaccines for use in larger animals such as primates.

Pre-clinical immunogenicity and efficacy trial of a recombinant hepatitis E vaccine.

We have demonstrated that recombinant hepatitis E vaccine suitable for clinical evaluation was highly immunogenic and efficacious in preventing hepatitis E and even infection in rhesus macaques following intravenous challenge with three different genotypes of hepatitis E virus (HEV). Two doses of vaccine were essential for optimal protection; the two-dose regimen was more important than the formulation of the vaccine for achieving efficacy. The titers of anti-HEV that were protective in this study were quantified against a World Health Organization (WHO) standard. This permits direct comparison of the results with other studies. The results of this pre-clinical trial of a candidate hepatitis E vaccine strongly suggest that it will be highly efficacious for preventing hepatitis E in the field trial of this vaccine that is currently in progress in Nepal.

Mutations that permit efficient replication of hepatitis C virus RNA in Huh-7 cells prevent productive replication in chimpanzees.

The development of a subgenomic replicon derived from the hepatitis C virus (HCV) strain Con1 enabled the study of viral RNA replication in Huh-7 cells. The level of replication of replicons, as well as full-length Con1 genomes, increased significantly by a combination of two adaptive mutations in NS3 (E1202G and T1280I) and a single mutation in NS5A (S2197P). However, these cell culture-adaptive mutations influenced in vivo infectivity. After intrahepatic transfection of chimpanzees, the wild-type Con1 genome was infectious and produced viral titers similar to those produced by other infectious HCV clones. Repeated independent transfections with RNA transcripts of a Con1 genome containing the three adaptive mutations failed to achieve active HCV infection. Furthermore, although a chimpanzee transfected with RNA transcripts of a Con1 genome with only the NS5A mutation became infected, this mutation was detected only in virus genomes recovered from serum at day 4; viruses recovered at day 7 had a reversion back to the original Con1 sequence. Our study demonstrates that mutations that are adaptive for replication of HCV in cell culture may be highly attenuating in vivo.

Identification of VP1/2A and 2C as virulence genes of hepatitis A virus and demonstration of genetic instability of 2C.

Fourteen different chimeric virus genomes were constructed from two infectious cDNA clones encoding a virulent and an attenuated isolate, respectively, of the HM175 strain of hepatitis A virus. The ability of each recombinant virus to infect tamarins and to cause acute hepatitis was determined. Comparisons of the genotype and phenotype of each virus suggested that VP1/2A and 2C genes were responsible for virulence. The 2C gene derived from the attenuated parent virus was unstable, and one or more mutations arose in this gene during the first passage in tamarins.

Relative infectivity of hepatitis A virus by the oral and intravenous routes in 2 species of nonhuman primates.

Hepatitis A virus (HAV) is naturally transmitted by the fecal-oral route but can also be transmitted intravenously. To determine the relative infectivity of these 2 routes, an infectivity titration of a standard challenge pool of virulent HAV was performed in tamarins and chimpanzees. In both species, 1 oral dose of HAV was equivalent to 10(4.5) intravenous doses. These findings have relevance for attempts to develop live, attenuated HAV vaccines that can be administered orally.

Caries dental / / Regeneración y trasplante de tejidos / Dental Clinics of North America

Prólogo. E. Johansen. Incidencia y distribución de la caries dental en los Estados Unidos. J. M. Dumming. Naturaleza de la lesión cariosa, E. Johansen. Bacterias y caries, H. Blechman. Alimentos, nutrición y caries dental, A. E. Nizel. SAliva y caries dental, S. Wah Leung. Factores hereditarios en la caries dental, O. Goodman. Aspectos bioquímicos de la caries dental, L. S. Fosdisck. Prevención de la caries dental: principios generales, J. F. Volker. Los fluoruros en la prevención de la caries dental, F. Brudevold. Prevención de la caries dental sin fluoruros, B. C.. Bibby

Prólogo, M. Shapiro. Algunos aspectos biológicos de los injertos óseos, A. Sicher. Métodos clínicos de valoración de la regeneración de los tejidos blandos periodontales luego de la intervención quirúrgica, P. N. Baer y S. Kakeshai. Regeneración de tejidos conjuntivos consecutiva al tratamiento, O. Glickman. Métodos para obtener la máxima regeneración en terapéutica periodontal, F. A. Carranza. Regeneración ósea: injertos de cartílago y tejido dental en bolsas periodontales, E. M. Schaffer, M. W. Packer. Implante de homoinjertos en bolsas periodontales, H. Kromer. Remineralización del esmalte y dentina, T. Koulourides. Trasplante dentario, W. C. Guralnick y L. V. Shulman. Problemas básicos en regeneración y trasplante, E. R. Costich. Factores en los trasplantes dentarios, H. S. Fleming. Homotrasplante de gérmenes dentarios cultivados, W. Lefkowitz. Reimplante y tratamiento de fracturas radiculares, B. Z. Rabinowitch

Caries dental / / Regeneración y trasplante de tejidos / Odontología Clínica de Norteamerica

Prólogo. E. Johansen. Incidencia y distribución de la caries dental en los Estados Unidos. J. M. Dumming. Naturaleza de la lesión cariosa, E. Johansen. Bacterias y caries, H. Blechman. Alimentos, nutrición y caries dental, A. E. Nizel. SAliva y caries dental, S. Wah Leung. Factores hereditarios en la caries dental, O. Goodman. Aspectos bioquímicos de la caries dental, L. S. Fosdisck. Prevención de la caries dental: principios generales, J. F. Volker. Los fluoruros en la prevención de la caries dental, F. Brudevold. Prevención de la caries dental sin fluoruros, B. C.. Bibby

Prólogo, M. Shapiro. Algunos aspectos biológicos de los injertos óseos, A. Sicher. Métodos clínicos de valoración de la regeneración de los tejidos blandos periodontales luego de la intervención quirúrgica, P. N. Baer y S. Kakeshai. Regeneración de tejidos conjuntivos consecutiva al tratamiento, O. Glickman. Métodos para obtener la máxima regeneración en terapéutica periodontal, F. A. Carranza. Regeneración ósea: injertos de cartílago y tejido dental en bolsas periodontales, E. M. Schaffer, M. W. Packer. Implante de homoinjertos en bolsas periodontales, H. Kromer. Remineralización del esmalte y dentina, T. Koulourides. Trasplante dentario, W. C. Guralnick y L. V. Shulman. Problemas básicos en regeneración y trasplante, E. R. Costich. Factores en los trasplantes dentarios, H. S. Fleming. Homotrasplante de gérmenes dentarios cultivados, W. Lefkowitz. Reimplante y tratamiento de fracturas radiculares, B. Z. Rabinowitch

Caries dental / / Regeneración y trasplante de tejidos / Dental Clinics or North America

Prólogo. E. Johansen. Incidencia y distribución de la caries dental en los Estados Unidos. J. M. Dumming. Naturaleza de la lesión cariosa, E. Johansen. Bacterias y caries, H. Blechman. Alimentos, nutrición y caries dental, A. E. Nizel. SAliva y caries dental, S. Wah Leung. Factores hereditarios en la caries dental, O. Goodman. Aspectos bioquímicos de la caries dental, L. S. Fosdisck. Prevención de la caries dental: principios generales, J. F. Volker. Los fluoruros en la prevención de la caries dental, F. Brudevold. Prevención de la caries dental sin fluoruros, B. C.. Bibby

Prólogo, M. Shapiro. Algunos aspectos biológicos de los injertos óseos, A. Sicher. Métodos clínicos de valoración de la regeneración de los tejidos blandos periodontales luego de la intervención quirúrgica, P. N. Baer y S. Kakeshai. Regeneración de tejidos conjuntivos consecutiva al tratamiento, O. Glickman. Métodos para obtener la máxima regeneración en terapéutica periodontal, F. A. Carranza. Regeneración ósea: injertos de cartílago y tejido dental en bolsas periodontales, E. M. Schaffer, M. W. Packer. Implante de homoinjertos en bolsas periodontales, H. Kromer. Remineralización del esmalte y dentina, T. Koulourides. Trasplante dentario, W. C. Guralnick y L. V. Shulman. Problemas básicos en regeneración y trasplante, E. R. Costich. Factores en los trasplantes dentarios, H. S. Fleming. Homotrasplante de gérmenes dentarios cultivados, W. Lefkowitz. Reimplante y tratamiento de fracturas radiculares, B. Z. Rabinowitch

Caries dental / / Regeneración y trasplante de tejidos / Dental Clinics of North America

Prólogo. E. Johansen. Incidencia y distribución de la caries dental en los Estados Unidos. J. M. Dumming. Naturaleza de la lesión cariosa, E. Johansen. Bacterias y caries, H. Blechman. Alimentos, nutrición y caries dental, A. E. Nizel. SAliva y caries dental, S. Wah Leung. Factores hereditarios en la caries dental, O. Goodman. Aspectos bioquímicos de la caries dental, L. S. Fosdisck. Prevención de la caries dental: principios generales, J. F. Volker. Los fluoruros en la prevención de la caries dental, F. Brudevold. Prevención de la caries dental sin fluoruros, B. C.. Bibby

Prólogo, M. Shapiro. Algunos aspectos biológicos de los injertos óseos, A. Sicher. Métodos clínicos de valoración de la regeneración de los tejidos blandos periodontales luego de la intervención quirúrgica, P. N. Baer y S. Kakeshai. Regeneración de tejidos conjuntivos consecutiva al tratamiento, O. Glickman. Métodos para obtener la máxima regeneración en terapéutica periodontal, F. A. Carranza. Regeneración ósea: injertos de cartílago y tejido dental en bolsas periodontales, E. M. Schaffer, M. W. Packer. Implante de homoinjertos en bolsas periodontales, H. Kromer. Remineralización del esmalte y dentina, T. Koulourides. Trasplante dentario, W. C. Guralnick y L. V. Shulman. Problemas básicos en regeneración y trasplante, E. R. Costich. Factores en los trasplantes dentarios, H. S. Fleming. Homotrasplante de gérmenes dentarios cultivados, W. Lefkowitz. Reimplante y tratamiento de fracturas radiculares, B. Z. Rabinowitch