Effect of Inpatient Medication-Assisted Therapy on Against-Medical-Advice Discharge and Readmission Rates.

BACKGROUND: Patients who present to the hospital for infectious complications of intravenous opioid use are at high risk for against-medical-advice discharge and readmissions. The role of medication-assisted treatment for inpatients is not clear. We aimed to assess outcomes prior to and after rollout of an inpatient buprenorphine-based opioid use disorder protocol, as well as to assess outcomes in general for medication-assisted therapy. METHODS: This was a retrospective observational cohort study at our community hospital in New Hampshire. The medical record was searched for inpatients with a complication of intravenous opioid use. We searched for admissions 11 months prior to and after the November 2018 buprenorphine protocol rollout. RESULTS: Rates of medication-assisted therapy usage and buprenorphine linkage increased significantly after protocol rollout. Rates of against-medical-advice discharge did not decrease after protocol rollout, nor did readmissions. However, when evaluating the entire group of patients regardless of date of presentation or protocol use, against-medical-advice discharge rates were substantially lower for patients receiving medication-assisted therapy compared with those receiving supportive care only (30.0% vs 59.6%). Readmissions rates were lower for patients who were discharged with any form of ongoing medication-assisted therapy compared with those who were not (30-day all-cause readmissions 18.8% vs 35.1%; 30-day opioid-related readmissions 10.1% vs 29.9%; 90-day all-cause readmissions 27.3% vs 42.7%; 90-day opioid-related readmissions 15.1% vs 33.3%). CONCLUSIONS: There is a strong association between medication-assisted therapy and reduced against-medical-advice discharge rates. Additionally, maintenance medication-assisted therapy at time of discharge is strongly associated with reduced readmissions rates.

Some of the earliest depictions of the human spine: a glimpse into European history.

INTRODUCTION: Drawings of the human form have a history almost as old as mankind itself. However, illustrations of the human spine as seen with the vertebral column were not seen until much later. This paper reviews some of the early European depictions of the human vertebral column from the twelfth (e.g., Fünfbilderserie "Bone-Man": 1152 A.D.) and thirteenth (e.g., Ashmole 1292) centuries. Man's understanding of his body has evolved over hundreds of years. CONCLUSIONS: This glimpse into our past and early drawings of the human spine illustrate how this particular anatomical structure was perceived almost a millennium ago and would not be structurally correct renditions until Leonardo da Vinci in the fifteenth century.

Cardiovascular disease risk profile of NCAA Division III intercollegiate football athletes: a pilot study.

OBJECTIVES: Concerns about the long-term cardiovascular health implications of American football participation have been investigated at the professional and Division I levels, but limited research is available at the less resourced Division III level. Therefore, the objective was to assess the cardiovascular disease risk profile of NCAA Division III intercollegiate football athletes. METHODS: Eighty-nine varsity football athletes (age = 19.6 ± 1.7 years, height = 1.81 ± 0.07m, weight = 92.7 ± 16.2kg; n = 21 linemen, n = 68 non-linemen) at a private Division III university volunteered to participate. During a preseason pre-participation physical examination, all participants completed a health history screening form (to assess personal and family history of cardiac related pathologies), and were assessed for height, weight, body mass index (BMI), and blood pressure (BP). Linemen only additionally gave a blood sample for fasting blood glucose and cholesterol analysis, and were assessed for waist and hip circumference, metabolic syndrome, and percent body fat (%BF). These measures were reported as averages and frequencies of elevated cardiovascular. Independent t-tests compared linemen to non-linemen, all other data was presented descriptively. RESULTS: On average, linemen were significantly taller, heavier, had a higher BMI and higher systolic BP than non-linemen (all P < 0.05); there was no difference in diastolic BP between the groups (P = 0.331). The average anthropometric and cardiac risk characteristics for linemen were largely within normal ranges, however analyzed individually, a substantial number of participants were at elevated risk (BMI ≥30 = 85.7%, %BF ≥25 = 71.4%, waist circumference ≥1 = 42.9%, hypertension = 9.5%, high density lipoproteins <40mg/dL = 42.9%, and triglycerides ≥150mg/dL = 6.7%; metabolic syndrome prevalence = 19%). CONCLUSIONS: Similar to research in elite athletics, linemen at a single Division III university have elevated cardiovascular disease risk. Physicians and other healthcare providers should consider this elevated risk during pre-participation physical examinations and in planning educational or dietary programming targeted to promoting cardiovascular health.

Nutrition practices and knowledge among NCAA Division III football players.

BACKGROUND: Participation in collegiate American football is physically demanding and may have long-term health implications, particularly in relation to cardiovascular and neurological health. National Collegiate Athletic Association (NCAA) Division III (DIII) football players are a relatively unstudied population, particularly in terms of their dietary habits and knowledge. The aim of the present study was to descriptively evaluate the dietary intake of DIII football players including a subset of linemen and assess the nutritional knowledge and sources of information of these athletes. METHODS: The study sample was 88 DIII football players including a subset of nine linemen. All participants completed a food frequency questionnaire, and a nutritional knowledge questionnaire that included a quiz and questions about their main sources of nutrition information. Heights and body masses were also recorded. The linemen submitted written 3-day diet records for assessment of their dietary intake. RESULTS: Of the 88 participants, >50% reported consuming starches/grains, meat and dairy daily, but <50% reported consuming fruits and vegetables daily. Protein powders were the most commonly used supplements (33% reported daily use). Compared to dietary recommendations, linemen consumed high amounts of total fat, saturated fat, dietary cholesterol, sodium, and potassium, but were low in carbohydrates, fiber, and essential fats. The mean nutrition knowledge quiz score for the 88 participants was 55.2%. Those who had taken a nutrition or health course in college scored significantly higher on the quiz than those who had not. Participants reported relying primarily on coaches, websites, and athletic trainers (ATs) for nutritional guidance; ATs were the most trusted source. CONCLUSIONS: DIII football players had dietary habits that may both mitigate and increase their risk of chronic diseases. These athletes have room to improve their nutrition knowledge. Their reliance on athletic team staff for nutrition guidance highlights the importance of nutrition education for both athletes and staff and the potential role of a registered dietitian nutritionist.

Lateral Transpsoas Approach to the Lumbar Spine and Relationship of the Ureter: Anatomic Study with Application to Minimizing Complications.

BACKGROUND: Complications from lateral lumbar interbody fusion procedures range from neurologic deficits to organ and blood vessel injuries. Injury to the ureter has been reported though uncommon. The present study was performed to elucidate the anatomic relationship of the ureter to this surgical approach. METHODS: Eight adult cadavers (16 sides) were placed in the full lateral position, and the distal ureter was cannulated with a metal wire that was passed up to the kidney. Fluoroscopy was used to establish the position of the ureter in relation to the bony anatomy in this region. RESULTS: In the lumbar region, there was a posterior to anterior course of the left and right ureter. From the direct lateral position, the ureter was found to lie at or posterior to the anterior edge of the lumbar vertebral bodies. On 87.5% of sides, the ureter was on average 2.5 cm posterior to the anterior border of the vertebral bodies at L2, 3 cm posterior at L3, 1.0 cm posterior at L4, and on the margin of the anterior vertebral bodies at L5. In general, the ureter, from a lateral perspective, crossed the posterior third of the upper lumbar vertebrae, approached the middle third at L3, and reached the anterior third at L4/L5 before descending into the pelvis. CONCLUSIONS: Owing to the proximity of the ureter to the lumbar vertebral bodies, it is imperative to verify that this structure is not in the surgical trajectory during lateral lumbar interbody fusion procedures if injury is to be avoided.

Lumbar Facet Tropism: A Comprehensive Review.

BACKGROUND: Scattered reports exist in the medical literature regarding facet tropism. However, this finding has had mixed conclusions regarding its origin and impact on the normal spine. METHODS: We performed a literature review of the anatomy, embryology, biomechanics, and pathology related to lumbar facet tropism. RESULTS: Facet tropism is most commonly found at L4-L5 vertebral segments and there is some evidence that this condition may lead to facet degenerative spondylolisthesis, intervertebral disc disease, and other degenerative conditions. CONCLUSION: Long-term analyses of patients are necessary to elucidate relationships between associated findings and facet tropism. In addition, a universally agreed definition that is more precise should be developed for future investigative studies.

New Landmark for Localizing the Site of the Subdental Synchondrosis Remnant: Application to Discerning Pathology from Normal on Imaging.

OBJECTIVE: We hypothesized that the entry site of the basivertebral vein into the basivertebral foramen of C2 might localize the subdental synchondrosis between the odontoid process and body of C2, which may be helpful for odontoid fracture classification. METHODS: Twenty-five dry adult C2 specimens underwent thin-cut computed tomography and were sectioned sagittally. The basivertebral foramen was then correlated to internal bony anatomy. Fifty magnetic resonance images were reviewed, and the location of the subdental synchondrosis was determined. RESULTS: A basivertebral foramen was identified on the posterior surface of all dry C2 specimens. The openings were found at a distance of 30%-44% on an inferosuperior point along the vertical height of C2. For bony specimens with a subdental synchondrosis remnant (75%), entry of acupuncture needles into the basivertebral foramen was always directly at the level of the synchondrosis remnant. For magnetic resonance imaging (MRI), a subdental synchondrosis or its remnants were seen on all studies. The distance from the base of C2 to the subdental synchondrosis ranged from 9-13 mm. This equated to an inferosuperior point 32%-43% along the vertical height of C2. A strong correlation existed when comparing the location of the basivertebral foramen of bony specimens and the subdental synchondrosis location on MRI. CONCLUSIONS: The basivertebral foramen is a consistently present anatomic reference point for the subdental synchondrosis even if the latter cannot be seen on conventional radiographic imaging. Our MRI data might also be useful in helping differentiate lesions affecting C2 from normal subdental cartilaginous remnants that can be encountered on imaging.

Do the cerebellar tonsils move during flexion and extension of the neck in patients with Chiari I malformation? A radiological study with clinical implications.

BACKGROUND: In the past, diagnosis of the Chiari I malformation has primarily been made on midsagittal MRI. We hypothesized that based on the frequent presentation of opisthotonos in patients with hindbrain hernia (primarily Chiari II malformation but sometimes Chiari I malformation) that the hyperextension might be a compensatory technique used by such patients to bring the cerebellar tonsils up out of the cervical spine. PATIENTS AND METHODS: This prospective study reviewed imaging of patients with Chiari I malformation who underwent flexion/extension MRI for evaluation of their hindbrain herniation. Age-matched controls were used for comparison. RESULTS: In general, there was elevation of the cerebellar tonsils with extension and increased descent with flexion of the cervical spine. In 72 % of patients, flexion of the neck resulted in descent of the cerebellar tonsils. In 64 % of patients, extension of the neck resulted in ascent of the cerebellar tonsils. In the 14 patients with an associated syrinx, 71 % were found to have caudal movement of the cerebellar tonsils with neck flexion, and only 43 % were observed to have any movement of the cerebellar tonsils in neck extension compared to patients without a syrinx where ascent of the tonsils was seen in only nine during neck extension. Two patients were observed to have the reverse finding of ascent of the cerebellar tonsils with neck flexion and descent of the cerebellar tonsils with neck extension. Five patients had no movement of the cerebellar tonsils in either flexion or extension of the neck, and one of these had a small syrinx. CONCLUSIONS: Although minimal and not in all patients, we observed elevation of the herniated cerebellar tonsils with extension of the cervical spine in patients with Chiari I malformation. This finding provides evidence as to why some patients with hindbrain herniation present with opisthotonos and supports earlier findings that CSF flow is reduced at the craniocervical junction in flexion in patients with Chiari I malformation.

Clinical recovery and circulating botulinum toxin type F in adult patient.

A 56-year-old woman in Helena, Montana, USA, who showed clinical signs of paralysis, received antitoxins to botulinum toxins A, B, and E within 24 hours; nevertheless, symptoms progressed to complete quadriplegia. On day 8, she began moving spontaneously, even though blood tests later showed botulinum toxin type F remained.