Opioid Overdose Knowledge Among Adolescents and Young Adults

This cross-sectional study examines awareness of opioid overdose, the ability to administer naloxone, and the willingness to help during an overdose on college campuses across the US.

The association between naloxone claims and proportion of independent vs. chain pharmacies: A longitudinal analysis of naloxone claims in the US

BACKGROUND

Expanding access to naloxone through pharmacies is an important policy goal. Our objective was to characterize national county-level naloxone dispensing of chain versus independent pharmacies.

METHODS

The primary exposure in our longitudinal analysis was the proportion of chain pharmacies in a county, identified through the US Department of Homeland Security 2010 Infrastructure Foundation-Level Data. We defined counties as having "higher proportion" of chain pharmacies if at least 50% of pharmacies were large national chains. The primary outcome was quarter-year (2016Q1-2019Q2) rate of pharmacy naloxone claims per 100,000 persons from Symphony Health at the county-level. We compared the naloxone dispensing rate between county types using two-sample t-tests. We estimated the association between county-level chain pharmacy proportion and rate of naloxone claims using a linear model with year-quarter fixed effects.

RESULTS

Nearly one third of counties (n=946) were higher proportion. Higher proportion counties had a significantly higher rate of naloxone claims across the study period, in 4 of 6 urban-rural classifications, and in counties with and without naloxone access laws. The linear model confirmed that higher proportion counties had a significantly higher rate of naloxone claims, adjusting for urban/rural designation, income, population characteristics, opioid mortality rate, co-prescribing laws and naloxone access laws.

CONCLUSION

In this national study, we found an association between naloxone dispensing rates and the county-level proportion of chain (versus independent) pharmacies. Incentivizing naloxone dispensing through educational, regulatory, or legal efforts may improve naloxone availability and dispensing rates - particularly in counties with proportionately high numbers of independent pharmacies.

Is Abstinence from Alcohol and Smoking Associated with Less Anxiety and Depressive Symptoms Among People with HIV?

Achieving abstinence from alcohol, tobacco, or both may improve mental health, but is understudied in people with HIV (PWH). The St PETER HIV randomized clinical trial compared varenicline, cytisine, and nicotine replacement therapy on alcohol and smoking behavior among 400 PWH in Russia. The primary exposure was thirty-day point prevalence abstinence (PPA) from (1) alcohol, (2) smoking, (3) both, or (4) neither and was assessed at 1, 3, 6 and 12-months as were the study outcomes of anxiety (GAD-7) and depressive (CES-D) symptoms. The primary aim was to examine the association between smoking and/or alcohol abstinence and subsequent symptoms of depression and anxiety. Primary analysis used repeated measures generalized linear modeling to relate PPA with mental health scores across time. In secondary analyses, Kruskal-Wallis tests related PPA with mental health scores at each timepoint. Primary analyses did not identify significant differences in anxiety or depressive symptoms between exposure groups over time. Secondary analyses found CES-D scores across PPA categories were similar at 1-month (11, 10, 11, 11) and 6-months (10, 10, 11, 11) but differed at 3-months (9, 11, 10, 12; p = 0.035) and 12-months (10, 6, 11, 10; p = 0.019). GAD-7 scores did not vary across PPA categories at any time point. While abstinence was associated with fewer depressive symptoms at times, findings were not consistent during follow-up, perhaps reflecting intermittent relapse. PWH with polysubstance use and mental health comorbidity are complex, and larger samples with sustained abstinence would further elucidate effects of abstinence on mental health.

Interventions to increase naloxone access for undergraduate students: A systematic review of the literature

OBJECTIVE

To identify and describe interventions that increase access to naloxone for undergraduate students.

METHODS

A systematic review across 4 databases identified interventions that expand access to naloxone at colleges in the United States from 2015-2023. Three reviewers extracted the following data to create a narrative synthesis and summary of program elements: setting, rationale for intervention, timeline, intervention components, study size, collaboration, sustainability, outcomes and results.

RESULTS

Seven articles met inclusion criteria. Institutions' implemented naloxone interventions due to concerns for student safety and/or student overdose fatalities. Three universities collaborated with their School of Pharmacy for program design and/or dissemination, while two partnered with state-based naloxone distribution programs. Most programs combined opioid-overdose/naloxone training; four distributed naloxone kits. Three studies included pre/post-outcomes, and all reported increases in participant knowledge, attitudes, and/or ability to respond to an overdose.

CONCLUSIONS

Our results indicates an opportunity for wide-scale implementation of undergraduate naloxone programs within US colleges. However, more rigorous implementation research is needed to identify barriers and facilitators to program feasibility, acceptability, and participation.

Healthcare Utilization Among Persons with HIV and Unhealthy Alcohol Use in St. Petersburg, Russia

Few studies have examined the association between healthcare utilization and heavy alcohol use in Russia among persons with HIV (PWH), a group with high healthcare needs. This study analyzed the association between unhealthy alcohol use (defined as AUDIT score ≥ 8) and healthcare utilization among PWH with heavy alcohol use and daily smoking in St. Petersburg, Russia. This secondary analysis used data from a randomized controlled trial addressing alcohol use. The primary outcome was seeing an infectionist for HIV care in the past year. Outcomes were measured at baseline, 6 months, and 12 months. We assessed the association between unhealthy alcohol use and healthcare utilization outcomes with a repeated measures logistic regression model, controlling for relevant covariates. Nearly all (96.0%) participants had unhealthy alcohol use at baseline, and 90.0% had seen an infectionist for HIV care in the past year. In adjusted analyses, unhealthy alcohol use was associated with a 36% decrease in seeing an infectionist for HIV care (aOR = 0.64, 95% CI 0.43-0.95). Participants reported low levels of emergency department visits and hospitalizations. Understanding how to engage this population in alcohol use disorder treatment and HIV care is an important next step for improving health outcomes for this population.

Rerupture and wound complications following Achilles tendon repair: A systematic review

Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.

Percutaneous Fixation of Unstable Proximal Phalanx Fractures: A Biomechanical Study

BACKGROUND

Unstable extra-articular proximal phalanx fractures are common injuries to the hand that are often treated by closed reduction and percutaneous pinning. Fracture-induced shortening of the proximal phalanx leads to an extensor lag at the proximal interphalangeal joint. We describe a biomechanical study in cadaver hands to compare the ability of each of three different pin configurations to resist shortening in unstable fractures.

METHODS

Seventeen fresh frozen hands were disarticulated at the proximal ends of the metacarpals. The second, third, and fourth proximal phalanges were tested. A 5-mm section of bone was resected from the mid-shaft of proximal phalanx to simulate an unstable fracture. Three techniques were employed and randomized for each finger: transmetacarpophalangeal joint pinning using 1 or 2 Kirschner wires (K-wires) and periarticular cross pinning using 2 K-wires. Compressive axial loads and energy at 1 mm, 2 mm, 3 mm, 4 mm, and 5 mm of subsidence were examined.

RESULTS

The forces and energy required to shorten the finger for each amount of subsidence were similar for all 3 pinning techniques and for all 3 finger types. Greater amounts of shortening were found to require larger forces.

CONCLUSION

Closed reduction and percutaneous pinning using any of the presented techniques is an adequate method of treatment for unstable proximal phalanx fractures. All of the techniques were equivalent in their ability to resist axial loading, regardless of the complexity of technique, the number of pins used, or finger that was pinned.

Revision Surgery and Wound Complications with Minimally Invasive Compared to Open Achilles Tendon Repair: A Retrospective Comparative Study of 116 Patients

The current study analyzed revision surgery rate and wound complications of patients with Achilles tendon ruptures that received either minimally invasive repair or open standard repair. A retrospective chart review of patients that had Achilles tendon repair performed using either an open or minimally invasive technique was conducted. Primary outcomes were revision surgery rate and wound complication rate. Twenty-nine (25.0%) patients had the minimally invasive approach, while 87 (75.0%) had the open approach. On average there were 0.16 additional surgeries per patient in the open group versus none in the minimally invasive group (p = 0.003). There were 13 wound-related complications, all of which were in the open group (p = 0.06). Revision surgery rates are significantly higher for patients treated with open Achilles repair versus those treated with a minimally invasive technique. Patients may benefit from a minimally invasive as opposed to open technique. (Journal of Surgical Orthopaedic Advances 32(3):173-176, 2023).

Health literacy, health outcomes and community health worker utilization: a cohort study in HIV primary care

Background

People with HIV (PWH) have complex needs, and those with limited health literacy consistently have poorer HIV-related knowledge and health outcomes. One strategy to facilitate better outcomes for PWH is the inclusion of community health workers (CHWs) into care teams. This cohort study examines the effect of health literacy on clinical outcomes and utilization of CHW services among PWH enrolled in a CHW intervention. The secondary aim is to characterize most common purposes of CHW encounters.

Methods

PWH (n = 209) enrolled in a CHW intervention with completed 6-month follow-up evaluation visits were included. Health literacy level was measured at baseline with the BRIEF tool and categorized into inadequate, marginal, and adequate health literacy. Adjusted logistic regressions assessed the effect of health literacy on viral load suppression, HIV primary care visits at 6-month follow-up, CHW utilization and purpose of CHW encounter. Purpose of CHW encounters included logistical support, accompany to appointment, transportation coordination, concrete services, coaching, and emotional support. Linear regression assessed the association between purpose of CHW encounters and CHW utilization.

Results

Individuals with inadequate health literacy were more likely to receive coaching from CHWs (p = 0.029), and individuals with marginal health literacy were more likely to have an HIV primary care visit at 6 months (p = 0.044). Individuals receiving transportation coordination, concrete services, coaching, and emotional support had more total CHW encounters.

Conclusions

Purpose of encounter was highly correlated with frequency of CHW encounters, while health literacy status was not. This suggests individuals receiving these services require more assistance from CHWs, regardless of health literacy level. Training CHWs to conduct comprehensive social needs assessment and screening for risk factors at the initial visit with clients can identify resources and guide CHW service delivery as part of the care team.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08634-7.

The role of increasing pharmacy and community distributed naloxone in the opioid overdose epidemic in Massachusetts, Rhode Island, and New York City

Background

Naloxone distributed to people at risk for opioid overdose has been associated with reduced overdose death rates; however, associations of retail pharmacy-distributed naloxone with overdose mortality have not been evaluated.

Methods

Our analytic cohort uses retail pharmacy claims data; three health departments' community distribution data; federal opioid overdose data; and American Community Survey data. Data were analyzed by 3-digit ZIP Code and calendar quarter-year (2016Q1-2018Q4), and weighted by population. We regressed opioid-related overdose mortality on retail-pharmacy and community naloxone distribution, and community-level demographics using a linear model, hypothesizing that areas with high overdose rates would have higher current levels of naloxone distribution but that increasing naloxone distribution from one quarter to the next would be associated with lower overdose.

Results

From Q1-2016 to Q4-2018, the unadjusted naloxone distribution rate increased from 97 to 257 kits per 100,000 persons, while the unadjusted opioid overdose mortality rate fell from 8.1 to 7.2 per 100,000 persons. The concurrent level of naloxone distribution (both pharmacy and community) was positively and significantly associated with fatal opioid overdose rates. We did not detect associations between change in naloxone distribution rates and overdose mortality.

Conclusion

Naloxone distribution volumes were correlated with fatal opioid overdose, suggesting medication was getting to communities where it was needed most. Amid high rates of overdose driven by fentanyl in the drug supply, our findings suggest additional prevention, treatment, and harm reduction interventions are required-and dramatically higher naloxone volumes needed-to reverse the opioid overdose crisis in the US.

Trends in the co-occurrence of substance use and mental health symptomatology in a national sample of US post-secondary students from 2009 to 2019

Objective: This study examined joint trends over time in associations between substance use (heavy drinking, cannabis, and cigarette smoking) and mental health concerns (depression, anxiety, and suicidal ideation) among US post-secondary students. Participants: Data came from 323,896 students participating in the Healthy Minds Study from 2009 to 2019, a national cross-sectional survey of US post-secondary students. Weighted two-level logistic regression models with a time by substance interaction term were used to predict mental health status. Results: Use of each substance was associated with a greater odds of students endorsing depression, anxiety, and suicidal ideation. Over time, the association with mental health concerns strengthened substantially for cannabis, modestly for heavy drinking, and remained stable for smoking. Conclusion: Given co-occurrence is common and increasing among post-secondary students, college and university health systems should prioritize early identification, psychoeducation, harm-reduction, and brief interventions to support students at risk.

The influence of race, sexual orientation and gender identity on mental health, substance use, and academic persistence during the COVID-19 pandemic: A cross-sectional study from a national sample of college students in the healthy minds study

Purpose

This study seeks to characterize substance use, mental health, and academic persistence in college students during the COVID-19 pandemic, emphasizing variations by race, sexual orientation, and gender identity.

Methods

National samples (n = 146,810) of undergraduate students from the Healthy Minds Study were compared in two time periods: Fall 2017-Winter 2020 (pre-COVID) and March-December 2020. Descriptive statistics were conducted including t-tests/chi square tests comparing differences between time periods. Logistic regressions were estimated for main outcomes: substance use (licit, illicit, none), anxiety and/or depression symptoms, and academic persistence (student confidence that they will finish their degree). Marginal effects of race, sexual orientation, and gender identity were reported for all logistic regressions.

Results

In March-December 2020, students had 1.70 higher odds of screening positive for anxiety and/or depression compared to pre-COVID semesters. Latinx, Black, and "other" race/ethnicity had significantly higher probabilities of screening positive, as did transgender and gender non-conforming (TGNC) and lesbian, gay, bisexual, and queer (LGBQ) students.;Students had 0.43 times lower odds of reporting substance use in March-December 2020. Asian, Black, and Latinx students had significantly lower probabilities of reporting substance use, as did TGNC and LGBQ students.; During the pandemic, most students (86.7%) report at least 1 day of academic impairment (emotional/mental difficulties that hurt academic performance) in the last month due to mental health (up from 79.9% pre-pandemic).

Conclusions

Using the most comprehensive mental health data in college student populations, this is the first study to describe the impact of the pandemic on undergraduate students' substance use, mental health, and academic persistence/impairment.

Under the Skin: The Relationship Between Subcutaneous Injection and Skin Infections Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are at increased risk for numerous negative health outcomes. Subcutaneous injections (aka skin popping) can result in greater risk of skin and soft tissue infections (SSTIs), but less is known about PWID who choose this route of administration. This study compares subcutaneous injectors to intravenous injectors, characterizes those who inject subcutaneously, and examines whether subcutaneous injection is associated with SSTIs in the past year.

METHODS

A cohort of hospitalized PWID (n = 252) were interviewed regarding injection-related behaviors, history of SSTI, and knowledge of subcutaneous injection risk. We examined differences between those who do and do not inject subcutaneously and used a negative binomial regression model to estimate adjusted odds associating subcutaneous injection and SSTI.

RESULTS

Participants averaged 38 years, with 58.3% male, 59.5% White, 20.6% Black, and 15.9% Latinx. PWID who performed subcutaneous injection were not demographically different from other PWID; however, the mean rate of past year SSTIs was higher for persons injecting subcutaneously than for those who did not (1.98 vs 0.96, P < 0.001). Persons injecting subcutaneously did not differ from those who injected intravenously in terms of their knowledge of subcutaneous injection risk (P = 0.112) and knowledge score was not associated with SSTIs (P = 0.457).

CONCLUSIONS

PWID who perform subcutaneous injections are demographically similar to other PWID but had higher rates of past year SSTIs. Knowledge of subcutaneous injection risk was not associated with SSTI risk.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Flexor tenosynovectomy in carpal tunnel syndrome as a screening tool for early diagnosis of amyloidosis

INTRODUCTION

Amyloidosis is a heterogeneous group of diseases that most often presents with advanced cardiac pathology. Another presentation of the disease can include symptoms consistent with carpal tunnel syndrome; however, the true incidence of amyloidosis in patients with carpal tunnel syndrome remains unclear.

METHODS

We performed a retrospective chart review on all patients who underwent an open carpal tunnel release, with tenosynovium biopsy by a single surgeon between 01/2000 and 12/2018. Samples were stored in formalin following hematoxylin-eosin or congo red staining. A total of 199 patients were excluded for incomplete records, and carpal tunnel release performed for traumatic or infectious etiologies. Histologic findings of the attending pathologist were examined and categorized as follows: amyloidosis, fibrous tissue, tenosynovitis/inflammation edematous, benign tenosynovium, and gout.

RESULTS

Exactly 898 open carpal tunnel releases were performed, and 699 patients were included for final analysis. In all patients, biopsies for histology with hematoxylin-eosin (HE) staining were taken; in those HE stains where amylogenic proteins were suspected (73 or 10.4%), a subsequent congo red staining was additionally performed which confirmed the diagnosis of amyloidosis in 10 patients (1.4% of the carpal tunnel procedures). Overall, 10 patients were identified and constituted 1.4% of all HE stains (n = 10/699) and 13.7% of all congo red stains (n = 10/73).

CONCLUSION

Our results suggest that the incidence of amyloidosis in the general CTS patient population may be as high as 1.4% with routine screening by synovial biopsy and the diagnosis should be considered as a potential cause. Level of Evidence: III, retrospective study.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Toward Successful and Sustainable Statewide Screening for Social Determinants of Health: Testing the Interest of Hospitals

The impact of social and behavioral factors on health outcomes are well defined in the field of public health. Additionally, characteristics such as race, ethnicity, and language have been proven to affect an individual's capacity to address health care needs. While these nonclinical components affect care, variations in screening methodology between organizations make it difficult to analyze data broadly. Standardized approaches can mitigate the impact of these factors but may be difficult to incorporate into an established workflow. The Connecticut Hospital Association identified social determinants of health (SDOH) as a factor affecting patient outcomes during a statewide collaborative on asthma. The goal of this quality improvement project was to explore change in workflow as a barrier to screening for SDOH in hospitals. Four hospitals participated in the pilot using a standardized screening tool to assess 662 patients; 62% (n = 410) were White, 11% (n = 76) were Black, 5% (n = 31) were classified as other, and 22% (n = 145) were in unknown race categories. Of those reporting needs, 438 (66%) had food-, housing-, or transportation-related needs. Qualitative interviews with staff from pilot hospitals were conducted. There were 3 main themes: the screening tool was easy to use; patients could be reluctant to reveal SDOH information; and lack of a standardized referral process made patient screening difficult to sustain or justify. The volume and magnitude of SDOH needs identified, along with the sense of helplessness expressed in qualitative interviews, reinforced the decision to implement a technology platform for screening, closed-loop referral, and outcome measurement.

Risk Factors for Anterior Tibial Tendon Pathology

BACKGROUND

Though the tibialis anterior (TA) serves a vital role in ankle dorsiflexion, there is little information regarding risk factors and demographic information that might predispose one to tendinopathy or rupture. This study investigates the features of patients in a single institution who presented with either TA tendinopathy or rupture. The circumstances surrounding rupture were also noted.

METHODS

ICD-9/10 codes were used to find patients who presented with TA pathology to 2 foot and ankle surgeons at 1 academic medical center from 2011 to 2018. Patient characteristics were noted, including age, sex, body mass index, and the presence of a gastrocnemius equinus contracture. Characteristics of patients with traumatic and atraumatic ruptures were compared.

RESULTS

Ninety-four patients presented between 2011 and 2018 (79 cases of tendinopathy and 15 ruptures). The average patient age was 56 years, and the ratio of women to men was 74:20 (3.7:1). With regard to those who experienced rupture, there were 2 ruptures directly related to athletic activity (traumatic), whereas 13 ruptures were found on examination with no overt history of injury (atraumatic). The average age for patients with traumatic ruptures was 39 years compared with 73 years for those with atraumatic rupture (P < .05).

CONCLUSION

This study investigates the features of patients in a single institution who presented with TA pathology. With regard to tendon ruptures, traumatic ruptures tend to occur in younger patients, whereas older patients are more likely to suffer atraumatic ruptures. Nonoperative treatment often appears to be effective for TA pathology.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Educational programs implemented for pharmacists after state passage of a standing order for naloxone: A systematic review of current practices

OBJECTIVE

This review describes the current educational interventions that have been created for pharmacists after the implementation of a standing order for naloxone.

METHODS

Search strategies were constructed for 3 databases (PubMed, SCOPUS, and CINAHL), which were queried between February 1, 2019, and March 5, 2019. Two reviewers independently screened 224 titles and abstracts from these databases. The descriptive criteria of each study, such as rationale, design, study location, population, and method of intervention, were included.

RESULTS

Eight articles met the inclusion criteria; 4 were delivered in person, 2 were online programs, and 2 used combined in-person and online methodologies. Of the 8 studies, 4 were delivered to practicing pharmacists, and 4 were designed for student pharmacists.

CONCLUSION

Pharmacists seem to engage in more overdose prevention behaviors after participating in the novel educational program as compared with taking the state-mandated training alone. Both student pharmacists and practicing pharmacists had promising postintervention results, with post-test scores indicating a statistically significant increase in knowledge or improvement in naloxone-relevant skills. The results of this review indicate the need to critically analyze the implementation of standing order laws for naloxone, specifically how pharmacists are being trained. The next steps include publication of existing best practices for educational interventions for pharmacists that may not currently be in the literature.

Top Tips for an Orthopaedic Surgeon's Practice

As orthopaedic surgeons become more specialized, it is important that they remain up to date in the diagnosis and management of common orthopaedic problems. These can include conditions encountered in the clinic and/or on call. It is important that practicing surgeons stay abreast of recognition and management of problems, not only for the patients, but also to avoid commonly missed conditions or less-than-optimal treatment. The orthopaedic surgeon should be aware of the top tips in multiple disciplines, including orthopaedic oncology, hand, and trauma.

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics

Background: The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Methods: Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. Results: In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ² = 0.07, P > .05) and complication rate (2.8% vs 1.6%, χ² = 0.01, P > .05) were found. Conclusions: Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis

BACKGROUND

The quantification of the costs of ankle fractures and their associated treatments has garnered increased attention in orthopaedics through cost-effectiveness analysis. The purpose of this study was to prospectively assess the direct and indirect costs of ankle fractures in operatively and nonoperatively treated patients.

METHODS

A prospective, observational, single-center study was performed. Adult patients presenting for an initial consult for an ankle fracture were enrolled and were followed until recurring indirect costs amounted to zero. Patients completed a cost form at every visit that assessed time away from work and the money spent in the last week on transportation, household chores, and self-care due to an ankle fracture. Direct cost data were obtained directly from the hospital billing department.

RESULTS

Sixty patients were included in this study. With regard to patient characteristics, the mean patient age was 46.5 years, 55% of patients were female, 10% of patients had diabetes, and 17% of patients were active smokers. Weber A fractures composed 12% of fractures, Weber B fractures composed 72% of fractures, and Weber C fractures composed 18% of fractures. Operatively treated patients (n = 37) had significantly higher total costs and direct costs compared with nonoperatively treated patients (p < 0.01). In all patients, losses from missed work accounted for the largest portion of total and indirect costs, with a mean percentage of 35.8% of the total cost. The mean period preceding return to work of the 39 employed patients was 11.2 weeks. Longer periods of return to work were significantly associated with surgical fixation and having less than a college-level education (p < 0.05). The mean time for recurring observed costs to cease was 19.1 weeks.

CONCLUSIONS

In patients treated operatively and nonoperatively, the largest discrete cost component was a specific indirect cost. Indirect costs accounted for a mean of 41.3% of the total cost. Although the majority of the direct costs of ankle fractures are accrued in the period immediately following the injury, indirect cost components will regularly be incurred for nearly 5 months and often longer. To capture the full economic impact of these injuries, future research should include detailed reporting on an intervention's impact on the indirect costs of ankle fractures.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgeons' Learning Curve of Renaissance Robotic Surgical System

INTRODUCTION

A few articles on robot-assisted pedicle screw placement described the learning curve but failed to report on the overall operative time, including cases in which the robotic system malfunctioned. The purpose of this study was to identify a single surgeon's learning curve including estimated blood loss, surgery time, anesthesia time, robot time, and complications.

METHODS

A retrospective study was performed between January 2016 and August 2018 for patients who underwent posterior spinal fusion using the Mazor robot. Based on the charts, the robot time, time of anesthesia, and surgery time were recorded, as were the complications, misplacement of screws, and blood loss.

RESULTS

Of 62 robot-assisted surgeries scheduled, only 46 were performed (74.2%) upon patients with a mean age of 63.3 ± 13.0 years. The mean follow-up time was 13.2 ± 8.0 months and most commonly a fusion from L4 to S1 was performed (20/46, 43.5%). A high improvement in estimated intraoperative blood loss was observed of 755.7 ± 344.7 mL (slope = -9.89). A decrease in time in anesthesia, surgery, and robotic usage was identified with a slope factor of -3.64 (R ² = .22, SE = 85.4, P < .005), -3.97 (R ² = 0.30, SE 75.8, P < .005), -0.69 (R ² = .07, SE = 27.8, P < .09), respectively. Furthermore, a decrease in pedicle screw insertion time and operative time was found (slope = -0.05, R ² = .02, SE = 3.4, P = .37). In total, 5 major complications (cases 8, 19, 21, 35, 43) and 6 minor complications (cases 4, 14, 15, 20, 29), were identified (21.7%) without any learning curve.

CONCLUSIONS

Robot pedicle screw insertion shows no major learning curve; however, the blood loss and the installation process of the system improved with experience.

LEVEL OF EVIDENCE

3.

Treatment of nonunions of the humeral shaft with nonvascularized fibular strut allograft: postoperative outcomes and review of a surgical technique

Hypothesis

Persistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects.

Methods

We conducted a retrospective review of a single surgeon's clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft.

Results

Thirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up.

Conclusion

Fibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Thumb Disability Examination (TDX) as a New Reliable Tool for Basal Joint Arthritis

Background  The general assessment of basal joint arthritis (BJA) is limited using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. This has been shown to be insensitive to pain and disability levels, leading to the development and validation of the thumb disability examination (TDX) as a specific tool for BJA in 2014. Objective  The goal of this study was to evaluate the reliability, sensitivity, and specificity of the TDX score for BJA. Methods  A multicenter BJA database was established in 2007 to collect prospective data. We evaluated the correlation between the TDX score, visual analog pain scale with activity (A-VAS), Eaton-Littler score, and grip strength using a Pearson test. Additionally, we evaluated the pre- and postintervention scores to assess their predictive values. Results  A total of 109 thumbs of 74 patients with TDX scores were evaluated. Females were more commonly affected (75.2%), and the mean age was 65.39 years (standard deviation: 10.04). The majority of participants were white (90.8%). A high correlation between TDX and A-VAS score (Pearson's correlation = 0.520; p  < 0.001) and between grip strength (Pearson's correlation = -0.336; p  < 0.005) and Eaton-Littler score (Pearson's correlation = 0.353' p  < 0.01) was identified. Additionally, when comparing pre- and post-intervention for all treatment groups and for operative intervention, significant differences in TDX scores were observed (both p ≤ 0.01). No significant differences could be identified for DASH score or A-VAS when assessing these same groups. Conclusion  The TDX score correlates to high Pearson's correlation values and p -values, especially in grip strength, Eaton-Littler score, A-VAS score, and pre-/postintervention for all treatment groups combined and when specifically assessing the surgical intervention group. As a result, it can be concluded that the TDX score is a specific tool for the assessment of BJA. Level of Evidence  This is a Level II, prospective comparative study.

Subtraction hemiarthroplasty in basal joint arthritis: A case report

BACKGROUND

Basal joint arthritis is a common disease which is especially present in post-menopausal women. A variety of procedures have been described once conservative treatment has failed. The purpose of our study is to present a novel surgical technique based on a clinical case with three-year follow-up which is highly effective, even after failure of previous procedures.

CASE SUMMARY

We present a case of a 39 year-old-woman who suffered from recurring, persistent, sharp left thumb pain for several years. After two operative procedures, she presented again with intolerable, sharp pain over the trapeziometacarpal joint, and wished to proceed with a pain relieving procedure or arthroplasty. Intraoperatively, the articular surfaces appeared well, without any bare areas of bone or eburnation, resulting in the decision to perform a “subtraction hemiarthroplasty”. A shortening osteotomy of the os trapezium was performed by removing a slice of 8-9 mm bone, without damaging the joint cartilages. The osteotomy was stabilized using two screws, the ligament and capsular tissue was suture imbricated, and a cut down on the translation and a dorsal radial ligament reconstruction were performed. Three years after the final procedure, a long-term follow-up demonstrates excellent results, pain free with full range-of-motion.

CONCLUSION

Subtraction hemiarthroplasty with ligament tightening imbrication and reconstruction of the radial ligament led to excellent results in motion and pain.

Radiographic Results of Unicortical Medial Malleolar Fracture Fixation

BACKGROUND:

Medial malleolar fractures commonly occur as part of rotational ankle fractures, which often require surgery. Different fixation techniques exist, including unicortical or bicortical lag-screw fixation. Bicortical screws that engage the lateral distal tibia have been noted to be biomechanically superior to unicortical ones with a lower failure rate. The authors of this study have used unicortical screws routinely. This study was initiated to investigate the clinical results of a large series of patients with unicortical medial malleolar fixation.

METHODS:

Patients who underwent unicortical medial malleolar fracture fixation between 2011 and 2017 were reviewed. In total, 461 ankle fractures were identified with a mean follow-up of 11.4 months (range, 3-57), of which 211 had a medial malleolar fracture. Eight patients were excluded as they did not follow up with the treating surgeons after surgery, leaving 203 patients for evaluation. The primary outcome was radiographic union. Any loss of reduction, complication, or subsequent surgery was recorded. Malunion was defined as greater than 2 mm displacement.

RESULTS:

There were 2 asymptomatic nonunions (1.0%), 1 delayed union that healed using an external bone growth stimulator (0.5%), and 2 malunions of the medial malleolus (1.0%) with 1 asymptomatic. The other patient developed posttraumatic osteoarthritis but has not yet required further surgery. None of these 5 patients required revision medial malleolar surgery. Ultimately, the union rate using unicortical medial malleolar fixation was 99.0% (201/203).

CONCLUSION:

Unicortical fixation of medial malleolar fractures resulted in consistently good healing. Even though biomechanical studies have shown that bicortical screws provide stronger fixation, our clinical results indicate that the need for this stronger fixation may be questionable.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Prevalence of Asymptomatic Achilles Tendinosis

BACKGROUND

Most patients who sustain Achilles tendon ruptures (ATRs) have no clinical symptoms prior to ATR. The objective of this study was to define the prevalence of ultrasound-detectable Achilles tendinopathy in asymptomatic patients in an at-risk group.

METHODS

This was a cross-sectional study that collected data from a group of volunteers. All participants were given IPAQ questionnaires to gauge daily activity level, in addition to a demographic form. Participants underwent a physical examination, Silfverskiold test, and an ultrasonographic examination to evaluate for presence of Achilles tendinopathy. Fifty-one volunteers (30 female, 21 male) and 102 Achilles tendons were assessed in this study. The mean age was 27.4±6.3, with an average BMI of 23.5±3.9. Ninety-two percent of participants were categorized as having moderate or high activity levels per the iPAQ questionnaire.

RESULTS

Sixteen tendons had at least 1 abnormality: 10 (9.8%) had hypoechoic foci, 9 (8.8%) had calcifications, 1 (0.9%) had increased vascularity, and 1 (0.9%) had a low-grade interstitial tear. Approximately 40% of patients were noted to have a gastroc equinus contracture on Silfverskiold testing. In addition, 14.7% of patients with a gastroc equinus had a hypoechoic focus compared to 8.6% of patients without gastroc equinus ( P = .5003). Logistic regression analysis demonstrated that an increased BMI was a significant risk factor for having an Achilles tendon abnormality on ultrasonography ( P < .01, odds ratio = 1.41).

CONCLUSION

In this study, 16% of the Achilles tendons were abnormal and had at least 1 abnormality on ultrasonography. This group of patients was generally young, healthy, and active, thus a group at risk for ATRs. Only 40% of patients had gastrocnemius equinus, although a slightly higher non-significant percentage of those with hypoechoic foci had gastrocnemius equinus. It may be advantageous to prophylactically treat these patients with rehabilitation exercises to minimize the risk of ATR.

LEVEL OF EVIDENCE

Level II, comparative prognostic study.

Quality measurement in the shunt treatment of hydrocephalus: analysis and risk adjustment of the Revision Quotient

OBJECT.: The Revision Quotient (RQ) has been defined as the ratio of the number of CSF shunt revisions to the number of new shunt insertions for a particular neurosurgical practice in a unit of time. The RQ has been proposed as a quality measure in the treatment of childhood hydrocephalus. The authors examined the construct validity of the RQ and explored the feasibility of risk stratification under this metric.

METHODS

The Kids' Inpatient Database for 1997, 2000, 2003, 2006, and 2009 was queried for admissions with diagnostic codes for hydrocephalus and procedural codes for CSF shunt insertion or revision. Revision quotients were calculated for hospitals that performed 12 or more shunt insertions annually. The univariate associations of hospital RQs with a variety of institutional descriptors were analyzed, and a generalized linear model of the RQ was constructed.

RESULTS

There were 12,244 admissions (34%) during which new shunts were inserted, and there were 23,349 admissions (66%) for shunt revision. Three hundred thirty-four annual RQs were calculated for 152 different hospitals. Analysis of variance in hospital RQs over the 5 years of study data supports the construct validity of the metric. The following factors were incorporated into a generalized linear model that accounted for 41% of the variance of the measured RQs: degree of pediatric specialization, proportion of initial case mix in the infant age group, and proportion with neoplastic hydrocephalus.

CONCLUSIONS

The RQ has construct validity. Risk adjustment is feasible, but the risk factors that were identified relate predominantly to patterns of patient flow through the health care system. Possible advantages of an alternative metric, the Surgical Activity Ratio, are discussed.