An Assessment of Physician Well-Being and Burnout Among Army Obstetricians and Gynecologists.

INTRODUCTION: Physician burnout is associated with unsafe patient care and poor patient satisfaction. Civilian studies show burnout rates of 46% among obstetricians/gynecologists (OB/GYNs). Army Active Duty (A-AD) physician burnout rates range from 7.7% to 26% across specialties, but no studies have assessed A-AD OB/GYN burnout. The objective of this study was to quantify well-being of A-AD OB/GYNs by determining rates of professional fulfillment (wellness) and burnout and detect factors of potential protective or risk for wellness and burnout. METHODS: A cross-sectional survey-based study was designed to determine well-being of A-AD OB/GYNs. This Institutional Review Board-approved study used the validated Professional Fulfillment Index. The survey was shared anonymously via email to 197 A-AD OB/GYNs. Additional questions asked as possible risk factors for burnout include location, training status, fellowship training, and remaining active duty service obligation (ADSO). Wellness and burnout rates were determined using published scales. Mean rates of wellness and burnout were reported, and chi-square tests detected associations between wellness/burnout and other variables. RESULTS: Eighty-three A-AD OB/GYNs responded to the survey (42%), with 73 available for full analysis. 26.5% had positive wellness, and 50% reported burnout. Completing fellowship training and shorter ADSO (of 0-2 years compared to >5 years) had higher rates of wellness. There were no differences in burnout among groups. CONCLUSIONS: Burnout rates in A-AD OB/GYNs appear higher than A-AD physicians of other specialties but are similar to civilian OB/GYNs. Fellowship training may confer higher rates of wellness. Further research is needed regarding improvements in A-AD OB/GYN well-being and burnout.

The Repair of an Acute Pathological Subtrochanteric Femur Fracture Using an Adult 3.5-mm Proximal Humerus Locking Plate in an Adolescent Patient: A Case Report.

CASE: We report a novel case of the successful repair of a pathological fracture of a 14-year-old boy's proximal femur using open reduction and internal fixation with an adult 3.5-mm proximal humerus locking plate. CONCLUSION: Successful repair of a pediatric pathologic femur fracture due to an aneurysmal bone cyst may be achieved using an adult proximal humerus locking plate in select patients.

Consensus and Controversies Between Pain and Addiction Experts on the Prevention, Diagnosis, and Management of Prescription Opioid Use Disorder.

OBJECTIVES: Prescription opioid use disorder (POUD) is an established public health crisis in many countries, and current evidence indicates it is a growing problem in Europe. Many specialists play a role, including pain and addiction medicine specialists, in the diagnosis and management of POUD, but neither group can fully address these patients' needs alone. The purpose of this consensus process was to bring together experts from pain and addiction medicine to examine the positions of both specialties. METHODS: In all, 13 international pain medicine, addiction medicine, and addiction psychiatry experts convened a meeting to formulate a set of consensus statements on the diagnosis and management of POUD. The statements were further refined by a wider group of 22 European expert clinicians. At a second meeting of all 35 participants, a set of controversy statements was also developed to recognize some of the key areas of divergent opinion. RESULTS/CONCLUSIONS: There was a high level of agreement between pain and addiction specialists. Key themes that emerged were the need to strengthen interdisciplinary communication, a desire for greater education and training for clinicians in both specialties, and mutual acknowledgment of the importance of multidisciplinary management of POUD. The blurred line between poorly managed pain and POUD was also a subject of much discussion, reflecting the difficulties in defining and diagnosing this complex condition.

Recommendations for the Prevention, Detection, Treatment and Management of Prescription Opioid Analgesic Dependence: Outcomes From the Opioid Analgesic Dependence Education Nexus (OPEN) Meeting.

The global consumption of opioids continues to rise, which has led to an increasing rate of diversion, misuse, addiction, and deaths related to prescription opioids. This has been particularly well documented in the USA; however, opioid analgesic dependence (OAD) is an increasing concern in Europe. More guidance is required for European healthcare professionals in the prevention, detection, treatment and management of OAD. The first Opioid Analgesic Dependence Education Nexus (OPEN) Mentor Meeting was held in Berlin in September 2014 to address this. An international Expert Panel, combining expertise in OAD from Australia, USA and Europe, invited 16 European experts in the pain and addiction fields to develop a best-practice approach to OAD that European practitioners can adopt. The outcomes from this meeting are presented here and included are a set of shared strategies that may be universally adopted by all healthcare professionals working with patients who use opioids.

The prevalence of vascular calcification in patients with end-stage renal disease on hemodialysis: a cross-sectional observational study.

BACKGROUND: This multicenter international cross-sectional observational study characterized vascular and valvular calcification burden and correlations with pulse pressure, diabetes, hypertension, and cardiovascular diseases in prevalent hemodialysis patients. METHODS: We enrolled 275 consecutive adults with end-stage renal disease on maintenance hemodialysis for ⩾3 months. Coprimary endpoints were prevalences of: (1) echocardiographic calcification in mitral valve, aortic valve or mitral annulus; (2) aortoiliac tree vascular calcifications by plain lateral lumbar X-ray. Correlations among calcification sites and with demographics and comorbidities were determined. Pulse pressures were determined. RESULTS: Subjects' mean ± standard deviation (SD) age was 56 ± 15.9 years; mean (SD) dialysis duration was 4.5 ± 4.3 years. Overall, 100% of echocardiographically imaged patients (n = 243) had calcification in aortic valve, mitral valve, or mitral annulus; 77.8% of X-rayed patients (n = 248) had abdominal aortic calcification. Radiographic abdominal aortic calcification score correlated significantly with calcification of aortic valve (p < 0.0001) and mitral annulus (p = 0.0001) but not mitral valve. Aortic valve, mitral valve, and mitral annulus calcification correlated significantly among themselves (p < 0.0001). Moderate/severe aortic valve calcification was significantly more prevalent in patients aged ⩾65 years than <65 years, men than women, and Whites than African Americans. Pulse pressure correlated significantly with vascular calcification score (p = 0.0049) but not with valvular calcification at any site. CONCLUSIONS: Vascular and valvular calcification are highly prevalent in the hemodialysis population. Peripheral vascular calcification correlates significantly with elevated pulse pressure and can be assessed easily using lateral lumbar X-ray. Further studies investigating the interaction between pulse pressure and development or progression of vascular calcification are of interest.

In Diabetic Kidney Disease Urinary Exosomes Better Represent Kidney Specific Protein Alterations Than Whole Urine.

BACKGROUND: Predicting or diagnosing underlying kidney disease by analyzing whole urine remains the mainstay of nephrology practice. However, whole urine is a poor compartment to assess many structural changes in the kidney because whole urine contains only a few proteins derived from the kidney itself. Urinary exosomes, on the other hand, which are derived from the kidney, contain proteins secreted by the kidney. We experimentally tested the hypothesis that 'urinary exosomes more faithfully represent changes in the kidney tissue than whole urine'. A direct comparison between whole urine and urine exosomal levels of two chosen kidney disease markers, gelatinase and ceruloplasmin, was carried out on diabetic kidney disease patients. METHODS: Urinary exosomes were separated from whole urine by sequential centrifugation including ultra-centrifugation. Gelatinase activity was measured using fluorosceinated gelatin as the substrate, and ceruloplasmin was measured by sandwich ELISA. A few kidney specimens from patients biopsied for atypical features were histochemically stained for validation of the biochemical results. RESULTS: We found that changes in both, gelatinase (decreased activity) and ceruloplasmin (increased levels), in the urinary exosomes of diabetic kidney patients were in agreement with the alterations of these two proteins in the kidney tissue. In contrast, the levels of these two proteins in whole urine were highly variable and did not correlate with levels in the diabetic kidney tissue. CONCLUSION: In conclusion, these results confirmed our hypothesis that protein markers in urinary exosomes better reflected the underlying protein changes in the kidney than in whole urine samples.

Resurgence of membranous nephropathy in African Americans in inner city Chicago.

BACKGROUND: It is well established that the incidence of focal segmental glomerular sclerosis (FSGS) increased from 1970-1990 to become the leading primary glomerular disease in patients of African descent. METHODS: To determine whether this trend has continued in the past years in Chicago, adult, native kidney biopsies from January 2001 to December 2011 at our hospital were reviewed and collected relevant clinical information in patients with a primary glomerular disease including FSGS, membranous nephropathy (MN), minimal change disease (MCD), membranoproliferative glomerulonephritis (MPGN), and IgA nephropathy (IgAN). RESULTS: In the 204 patients analyzed, MN was the most prevalent (32.7%), followed by FSGS (29.7%), IgAN (15.8%), MCD (14.4%), and MPGN (4.5%). Patients with MN had the highest proteinuria (7.9 gms/d) and were significantly older, more edematous, hypoalbuminemic, and hypercholesterolemic than those with FSGS. In both African Americans and Hispanics, MN was the most prevalent primary glomerular lesion at 39.2% and 34% respectively. CONCLUSIONS: Comparable in size to prior cohorts of African Americans and Hispanics, our report demonstrates a reversal in the incidence of FSGS and MN in both ethnic groups where MN is now more prevalent. To our knowledge, this is the first demonstration of a reverse in the upward trend of the prevalence of FSGS in African Americans.

Statement of the American Society Of Addiction Medicine Consensus Panel on the use of buprenorphine in office-based treatment of opioid addiction.

OBJECTIVES: Opioid addiction affects over 2 million patients in the United States. The advent of buprenorphine and the passage of the Drug Addiction Treatment Act in 2000 have revolutionized the opioid treatment delivery system by granting physicians the ability to administer office-based opioid treatment (OBOT), thereby giving patients greater access to treatment. The purpose of this consensus panel was to synthesize the most current evidence on the use of buprenorphine in the office-based setting and to make recommendations that will enable and allow additional physicians to begin to treat opioid-addicted individuals. METHODS: Literature published from 2000 to 2009 was searched using the PubMed search engine and yielded over 375 articles published in peer-reviewed journals, including some that were published guidelines. These articles were submitted to a consensus panel composed of researchers, educators, and clinicians who are leaders in the field of addiction medicine with specific expertise in the use of OBOT. The panel discussed results and agreed upon consensus recommendations for several facets of OBOT. RESULTS: : On the basis of the literature review and consensus discussions, the panel developed a series of findings, conclusions, and recommendations regarding the use of buprenorphine in office-based treatment of opioid addiction. CONCLUSIONS: Therapeutic outcomes for patients who self-select office-based treatment with buprenorphine are essentially comparable to those seen in patients treated with methadone programs. There are few absolute contraindications to the use of buprenorphine, although the experience and skill levels of treating physicians can vary considerably, as can access to the resources needed to treat comorbid medical or psychiatric conditions--all of which affect outcomes. It is important to conduct a targeted assessment of every patient to confirm that the provider has resources available to meet the patient's needs. Patients should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated, referred, or both for help in meeting all their care needs, including medical care, psychiatric care, and social assistance. Current literature demonstrates promising efficacy of buprenorphine, though further research will continue to demonstrate its effectiveness for special populations, such as adolescents, pregnant women, and other vulnerable populations. Since the time of this review, several new studies have provided new data to continue to improve our understanding of the safety and efficacy of buprenorphine for special patient populations.

Culture of omentum-induced regenerating liver yielded hepatocyte-committed stem cells.

Earlier we showed that when omentum, activated by inert particles, is allowed to fuse to a wedge cut in the liver, it induces stem cell proliferation in the liver resulting in massive liver regeneration. Here, we attempt to culture stem cells from the omentum-induced regenerating liver tissue. Cells from regenerating liver tissue were harvested and cultured. Cultured cells were characterized by immune staining, fluorescence activated cell sorting analysis, growth factor assay, in vitro differentiation, and their ability to engraft to injured sites in vivo. Culture yielded cells with a mesenchymal stem cell phenotype that could be maintained in culture indefinitely. These cells, called regenerating liver stem cells, expressed both adult and embryonic stem cell markers, secreted high levels of vascular endothelial growth factor, and expressed albumin. When grown on matrigel in the presence of hepatocyte growth factor, these cells differentiated into hepatocyte-like cells in culture, but they did not differentiate to adipogenic and osteogenic lineages when grown in specific differentiation medium. The differentiated cells expressed α-fetoprotein and secreted high levels of albumin and urea. After systemic injection, the undifferentiated cells engrafted only to the injured sites in the liver and not to the normal areas of the liver. In conclusion, omentum-induced regenerating liver yields hepatocyte-committed stem cells in culture. Such cells could prove to be useful in cell transplantation therapies.

Omentum facilitates liver regeneration.

AIM: To investigate the mechanism of liver regeneration induced by fusing the omentum to a small traumatic injury created in the liver. We studied three groups of rats. In one group the rats were omentectomized; in another group the omentum was left in situ and was not activated, and in the third group the omentum was activated by polydextran particles. METHODS: We pre-activated the omentum by injecting polydextran particles and then made a small wedge wound in the rat liver to allow the omentum to fuse to the wound. We monitored the regeneration of the liver by determining the ratio of liver weight/body weight, by histological evaluation (including immune staining for cytokeratin-19, an oval cell marker), and by testing for developmental gene activation using reverse transcription polymerase chain reaction (RT-PCR). RESULTS: There was no liver regeneration in the omentectomized rats, nor was there significant regeneration when the omentum was not activated, even though in this instance the omentum had fused with the liver. In contrast, the liver in the rats with the activated omentum expanded to a size 50% greater than the original, and there was histologically an interlying tissue between the wounded liver and the activated omentum in which bile ducts, containing cytokeratin-19 positive oval cells, extended from the wound edge. In this interlying tissue, oval cells were abundant and appeared to proliferate to form new liver tissue. In rats pre-treated with drugs that inhibited hepatocyte growth, liver proliferation was ongoing, indicating that regeneration of the liver was the result of oval cell expansion. CONCLUSION: Activated omentum facilitates liver regeneration following injury by a mechanism that depends largely on oval cell proliferation.

Buffered platelet-rich plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation.

The success of tissue engineering applications can potentially be dramatically improved with the addition of adjuncts that increase the proliferation and differentiation of progenitor or stem cells. Platelet-rich plasma (PRP) has recently emerged as a potential biologic tool to treat acute and chronic tendon disorders. The regenerative potential of PRP is based on the release of growth factors that occurs with platelet rupture. Its autologous nature gives it a significant advantage in tissue engineering applications. To test whether PRP may be useful specifically for cartilage regeneration, a cell culture experiment was devised in which mesenchymal stem cells (MSCs) were grown in control media or media enhanced with inactivated, buffered PRP. Proliferation 7 days after PRP treatment was increased: 1.041 versus 0.199 for the control media cells ( p<0.001). The messenger RNA (mRNA) level of the osteogenic marker RUNX2 was 52.84 versus 26.88 for the control group ( p<0.005). Likewise the mRNA level of the chondrogenic markers Sox-9 and aggrecan was 29.74 versus 2.29 for the control group ( p<0.001) and 21.04 versus 1.93 ( p<0.001), respectively. These results confirm that PRP enhances MSC proliferation and suggest that PRP causes chondrogenic differentiation of MSC in vitro.

2008 update on addiction medicine/psychiatry in the State of Connecticut. Part II of II.

No other health or social problem impacts our society so widely and profoundly as substance abuse. Investment in Connecticut's substance abuse service system is an investment in improved health and wellness its cities as well as its citizens. Since 2004 Connecticut's addiction treatment and recovery community have worked together to reduce the pain and suffering of those individuals with addiction disorders. The State of Connecticut is a national leader in addiction medicine scientific research and education, emergencyroom care, and public policy; and the Community of Addiction Recovery (CCAR) has emerged as a national leader for the recovery movement. As Chairperson ofthe CSMS's Committee on Alcohol and Other Drug Dependency Education, I am proud of the accomplishments of the Committee and the work of our statewide addiction medicine/psychiatryleaders and recovery community. I am equally proud and appreciative of the ongoing relationship of the CSMS, the addiction treatment and recovery community with DMHAS. Under the leadership of Commissioner Thomas Kirk, DMHAS has opened its arms to embrace the communities' providers. The work of these leaders is presented here to give readers an update on Addiction Medicine/Psychiatry in the State of Connecticut 2008.

Idiopathic hypocomplementemic immune-complex-mediated tubulointerstitial nephritis.

BACKGROUND: A 42-year-old man presenting with flank pain was found to have renal failure with severe hypocomplementemia and eosinophilia. INVESTIGATIONS: Physical examination, laboratory testing, renal ultrasonography, and renal biopsies. DIAGNOSIS: Acute immune-complex-mediated tubulointerstitial nephritis. MANAGEMENT: Immunosuppressive therapy with 1 mg/kg/day prednisone.

Hemorrhagic angiomyolipoma and tuberous sclerosis complex: a case report.

Tuberous sclerosis was first described in 1862 by von Recklinghausen. Since then there have been many advances in our understanding of the diagnosis, pathogenesis, and treatment of this disease complex, especially after it was characterized genetically. While many patients who have tuberous sclerosis present with the classic triad of mental retardation, seizures, and facial "adenoma sebaceum," most do not because of its variable penetrance. The diagnostic criteria have been revised to include patients with tuberous sclerosis who do not match the classic pattern. Here we describe a 44-year-old female without a prior diagnosis who did not have the classic triad but who presented with flank pain. Hemorrhagic angiomyolipoma was diagnosed by computerized tomography scan and she was treated by an embolization procedure. We review tuberous sclerosis and underscore the need to consider this diagnosis for the following reasons: 1. it is not uncommon (slightly more than one in 6,000 live births); 2. its presentation is protean; 3. once the diagnosis is made, search can be made for associated findings that may lead to additional morbidity if not carefully managed, e.g., if an angio-myolipoma is diagnosed, it can be followed and possibly treated; and 4. owing to its autosomal dominant pattern of inheritance, members of the family can be screened appropriately.