Reducing overdose deaths among persons with opioid use disorder in connecticut.

BACKGROUND: People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary. METHODS: We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons. RESULTS: Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime. CONCLUSIONS: Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

Aortomitral curtain reconstruction: demystifying a complicated situation.

The definitive management of an aortic root abscess is an operation associated with high morbidity and mortality. These operations are convoluted, time-consuming, and involve conceptionally intricate reconstructions. Following debridement of periannular abscesses, several challenges may persist, with one common issue being the destruction of the aortomitral curtain. Considering the daunting nature of this situation, the authors describe a step-by-step bovine pericardial patch reconstruction of the aortomitral curtain that endeavours to provide a simplified explanation for its use by a broader audience.

A Novel Technique for Performing Transfemoral Transcatheter Self-Expanding Aortic Valve Replacement With No Contrast Which Minimizes Acute Kidney Injury.

Transcatheter aortic valve replacement (TAVR) treats severe aortic stenosis. However, patients with limited renal function may be ineligible for contrast use during valve deployment. We evaluate TAVR via transfemoral approach using 2-wire technique and no contrast injection. Primary endpoints are acute kidney injury and procedural success. Safety analysis includes mortality, stroke, myocardial infarction, coronary obstruction, and more. Forty-six patients were included; most with preserved ejection fraction. Baseline creatinine was 1.63 ± 0.68 and post-TAVR was significantly better (1.47 ± 0.64, P < 0.01). No statistical difference existed between creatinine at baseline and 30 days. After TAVR, 91% had no paravalvular leak (PVL). Peak-velocity post-TAVR was 1.32 ± 0.33 and mean-gradient was 7 ± 4. No valve repositioning during deployment was required. No mortality at 30 days without incidence of stroke, myocardial infarction or coronary obstruction. One patient had retroperitoneal bleeding requiring transfusion. The noncontrast technique for self-expanding valve deployment is feasible and safe in patients who cannot tolerate contrast.

Zero to Hero? Reducing the Rate of Acute Kidney Injury in Transcatheter Aortic Valve Replacement: The Low Contrast Approach.

Background: Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) increases hospital stay, morbidity, and mortality, and the amount of contrast used during the procedure has been linked to the occurrence of AKI. Reducing the amount of contrast used during TAVR is hypothesized to decrease AKI without compromising outcomes. Methods: We conducted a single-institution retrospective analysis of patients who underwent TAVR from 2017 to 2019. Patients receiving ≤20 mL of contrast were labeled as group I, and patients receiving >20 mL of contrast were labeled as group II. Primary endpoints were 30-day mortality, AKI, and early aortic regurgitation. Results: A total of 594 patients met the inclusion and exclusion criteria, with 429 patients (72.2%) included in group I and 165 patients (27.8%) included in group II. Two hundred eighteen patients (50.8%) from group I and 41 patients (24.8%) from group II had preoperative chronic kidney disease stage III or IV. The mean contrast volume was 8.5 ± 6 mL for group I and 33 ± 16 mL for group II (P<0.001). In group I, 13 patients (3.0%) developed AKI, and 6 (1.4%) required hemodialysis. In group II, 9 (5.5%) patients developed AKI, and 1 (0.6%) required hemodialysis. The differences between the 2 groups for AKI and hemodialysis were not statistically significant. Overall, 579 patients (97.5%) had less than moderate aortic regurgitation in the postoperative echocardiogram. Conclusion: Low contrast TAVR is safe and effective and can reduce the incidence of AKI when compared to the standard contrast dose without affecting outcomes such as death and aortic regurgitation.

Wound-Induced Syncytia Outpace Mononucleate Neighbors during Drosophila Wound Repair.

All organisms have evolved to respond to injury. Cell behaviors like proliferation, migration, and invasion replace missing cells and close wounds. However, the role of other wound-induced cell behaviors is not understood, including the formation of syncytia (multinucleated cells). Wound-induced epithelial syncytia were first reported around puncture wounds in post-mitotic Drosophila epidermal tissues, but have more recently been reported in mitotically competent tissues such as the Drosophila pupal epidermis and zebrafish epicardium. The presence of wound-induced syncytia in mitotically active tissues suggests that syncytia offer adaptive benefits, but it is unknown what those benefits are. Here, we use in vivo live imaging to analyze wound-induced syncytia in mitotically competent Drosophila pupae. We find that almost half the epithelial cells near a wound fuse to form large syncytia. These syncytia use several routes to speed wound repair: they outpace diploid cells to complete wound closure; they reduce cell intercalation during wound closure; and they pool the resources of their component cells to concentrate them toward the wound. In addition to wound healing, these properties of syncytia are likely to contribute to their roles in development and pathology.

The cost of caring: How advanced cancer patients affect Caregiver's employment in Singapore.

BACKGROUND: With ageing populations and rising cancer incidence, more people are becoming informal caregivers. Informal caregivers are less likely to work than non-caregivers, yet little is known about how their employment changes over time. This study aimed to examine the association between decline in cancer patient's health (termed health shock) and caregiver's employment. A secondary aim was to assess characteristics of caregivers who stayed employed despite the health shock and the burden of caring for advanced stage cancer patients. METHOD: This study used data from 270 dyads of advanced cancer patients and their caregivers who participated in the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore study. The dyads were interviewed every 3 months for 2 years. Fixed-effects regression was used to analyse the association between patient health shock and two caregiver employment outcomes (i.e., employment status and work disruptions). RESULTS: Ninety-seven% of caregivers whose patient experienced a health shock reported work disruptions. About 13% of caregivers whose patient experienced at least one health shock left employment, compared to 5% of those whose patient did not experience any health shock. Following a patient health shock, caregivers were significantly less likely to be employed (ß: -0.03; 95% CI, -0.05 to -0.001) and more likely to experience work disruptions (ß: 0.06; 95% confidence interval [CI], -0.01 to 0.12). Caregivers who were young, educated, unmarried, not spousal caregivers, and not living with their patients were more likely to stay employed despite patient health shock (p < 0.01 for all). CONCLUSION: Findings show that caregivers' employment is affected by their patients' health through the caregiving trajectory. Continuous support for caregivers catered to specific vulnerable subgroups may be important to keeping caregivers in the workforce.