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Heart failure is a common, serious condition associated with frequent exacerbations and hospitalizations. Preventable causes of more than 70% of heart failure hospitalizations are attributable to ineffective heart failure self-care, including symptom recognition and interpretation, and delayed symptom reporting and treatment seeking. The social context in which illness symptoms occur is an important aspect of symptom self-management. Self-initiated medical and nonmedical treatments for symptom relief and engaging in lay consultations with persons in social networks for symptom evaluation are common. This article highlights socially delineated aspects of symptom self-management leading to hospitalization, many of which are amenable to nursing intervention.

Background Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. Methods A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013–2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. Results Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). Conclusion Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

BACKGROUND: Enrollment in smoking cessation trials remain sub-optimal. The aim of this analysis was to determine the effectiveness of a modified Zelen’s design in engaging hospitalized patients who smoke in a pragmatic OPT-IN versus OPT-OUT tobacco treatment trial. METHODS: At bedside, clinical staff screened smokers for eligibility, randomized eligible into study arms, and delivered the appropriate treatment approach. Study staff called randomized patients at one-month post-discharge, debriefed patients on the study design, and collected consent to participate. We used frequencies and percentages for categorical variables and means and standard deviations for quantitative variables to describe the characteristics of those who consented and were enrolled versus those who did not enroll. We also compared the characteristics of participants who consented and those who were reached and explicitly refused consent at one-month follow-up. We used the Cohen’s d measure of effect size to evaluate differences. RESULTS: Of the 1,000 randomized, 741 (74.1%) consented to continue in the study at one-month follow-up. One hundred and twenty-seven (12.7%) refused consent and 132 (13.2%) were unreachable. Cohen’s d effect size differences between those who consented/enrolled (n = 741) and those who were not enrolled (n = 259) were negligible (

Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications.A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed.Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37).Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

Given global trends in obesity and bariatric surgeries, there are an increasing number of women presenting for breast reconstruction after massive weight loss. There is a paucity of literature about breast reconstruction after mastectomy in patients with a history of massive weight loss. A literature review revealed 10 articles that discussed outcomes of different reconstruction techniques in patients with massive weight loss. Autologous reconstruction techniques and implant-based reconstruction techniques were assessed to evaluate the advantages, disadvantages, and indications of each approach specific to this unique patient population. This article provides a summary of expected outcomes, including complication profiles. Ultimately, consideration should be given for breast reconstruction of mastectomy defects in patients with a history of massive weight loss, as satisfactory results are demonstrated to be possible. Both autologous reconstruction and implant-based reconstruction present feasible options, although reconstruction in this patient population may be associated with increased need for revisions and a higher complication rate compared with patients without a history of massive weight loss. For this reason, it is imperative to appropriately manage preoperative expectations in patients with a history of massive weight loss.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with

Background: In Kenya, standard early infant diagnosis (EID) with polymerase chain reaction (PCR) testing at 6-week postnatal achieves early treatment initiation (

Current rates of opioid prescribing and consumption in the United States have resulted in deleterious consequences for both patients and society. There has been a focus on opioid consumption and overprescribing, but the utility of patient education in reducing opioid consumption has only recently been explored. This randomized trial aimed to evaluate the effectiveness of a brief patient educational intervention in reducing pain and opioid consumption in patients undergoing mastectomy and breast reconstruction. A parallel, randomized, single-center trial of women undergoing mastectomy with immediate, implant-based breast reconstruction was completed to evaluate the utility of a patient educational instrument with information on multi-modal pain control. A questionnaire was administered postoperatively to collect data on pain control and opioid consumption. Fifty participants were randomized to each group preoperatively; 46 control (92%) and 39 intervention (78%) participants completed the postoperative questionnaire. Active tobacco use was more common in the control group (p = 0.04). There was a trend towards lower pain scores in the intervention group (3.0/10, SD 1.8 vs 3.6/10, SD 1.6, p = 0.06). Both groups were prescribed a median of 32.0 5-mg oxycodone tablets postoperatively. Participants in the intervention group consumed 33% fewer opioids than the control group (16.2 tablets, SD 16.4 vs 24.3 tablets, SD 21.8, p = 0.05). The use of a brief educational intervention provided at a preoperative appointment can reduce opioid consumption. We recommend the use of an educational intervention to decrease opioid consumption among breast surgery patients.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

BackgroundAdult immunization rates are belowHealthy People 2020targets. Our objective was to evaluate the effectiveness of a multicomponent intervention to improve adult immunization rates.MethodsThis prospective interventional before-and-after non-randomized study was conducted through the American Academy of Family Physicians National Research Network with 43 primary care physicians from a large multi-specialty healthcare organization (multicomponent intervention groupn = 23; comparator groupn = 20) in the United States. The multicomponent intervention included provider reminders, quarterly provider-level performance reports, provider education, patient visual aid materials, and standing orders on adult pneumococcal, influenza, and zoster immunizations. We assessed individual and comparative provider-level vaccination rates and missed opportunities detailing concordance with targets established by Healthy People 2020 for pneumococcal, influenza, and zoster immunizations.ResultsVaccination rates increased after 12 months in intervention and comparator groups respectively for: a). influenza from 44.4 ± 16.7 to 51.3% ± 12.9% (by 6.9 percentage points,p = 0.001) and from 35.1 ± 19.1 to 41.3% ± 14.2%, (by 6.2 percentage points,p = 0.01); b). pneumococcal vaccinations in older adults from 62.8 ± 17.6 to 81.4% ± 16.6% (by 18.6 percentage points, forp p p p = 0.001). Pneumococcal vaccinations in adults at risk did not change from baseline in intervention group (35.7 ± 19.6 to 34.5% ± 19.0%,p = 0.3) and improved slightly in comparator group (24.3 ± 20.1 to 28.2% ± 20.0%,p = 0.003). Missed opportunities reduced after 12 months, most noticeably, for: a). for influenza from 57.7 to 48.6% (by 9.1 percentage points,p p p p ConclusionsMulticomponent interventions show promise in improving vaccination rates and reducing missed opportunities in older adults for pneumococcal and zoster vaccines and vaccination against influenza. Provider reminders remain the most effective strategy when delivered either as a component of these interventions or alone.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

We identified mortality predictors among HIV-exposed uninfected infants and infants living with HIV in Kenyan early infant diagnosis services between 2012 and 2017. Younger maternal age and absence of antenatal antiretroviral therapy among HIV-exposed uninfected infants (n = 2366) and travel time to hospital and delayed infant testing among infants living with HIV (n = 130) predicted mortality, highlighting the importance of supporting engagement in maternal/pediatric HIV services.

Background Inherited coagulopathies and previous thrombotic events are often considered relative contraindications to microvascular reconstruction. We hypothesize that with planning, head and neck microvascular reconstruction can be successfully performed in hypercoagulable individuals. Methods A retrospective review was conducted of subjects with coagulopathies or previous thrombotic events who underwent microvascular head and neck reconstruction. Outcomes studied were “flap-related complications” (arterial/venous compromise or flap loss) and “patient-related complications” (hematoma, deep venous thrombosis, pulmonary embolism, infection, stroke, or death). Results One hundred thirty-four microvascular flaps were performed in 117 subjects. Twenty-four subjects (20.5%) had a preoperative hypercoagulable condition and underwent 28 microvascular reconstructions. Twenty-three of 24 subjects had a previous thrombotic event, with five subjects identified with an inherited or acquired coagulopathy. All microvascular reconstructions were successful; however, complications occurred in 12 of 28 reconstructions (42.9%). Complications were “flap related” in four reconstructions (14.3%), “patient related” in nine reconstructions (32.1%), and both in one reconstruction (3.6%). Flap-related complications included small partial flap loss (n = 2), arterial compromise (n = 1), and venous compromise (n = 1), with all undergoing successful salvage. Patient-related complications included hematoma (n = 3), pulmonary embolism (n = 2), infection (n = 2), deep venous thrombosis (n = 1), and death (n = 1). Statistical analysis demonstrated that complications were more common in subjects with inferior vena cava filters (p = 0.06) and hematomas were associated with the use of therapeutic heparin infusion (p = 0.04). Conclusion Microvascular head and neck reconstruction can be successfully performed in hypercoagulable subjects. However, patient-related complications remain a concern in these subjects.

OBJECTIVE: To determine the prevalence and predictors of receiving a smoking cessation medication prescription at discharge. METHODS: Retrospective analysis of ongoing Human Studies Committee-approved clinical trial data at large tertiary care center, The University of Kansas Medical Center. Patients included were smokers over 18, either Spanish or English speaking, those admitted between October 1, 2016 through May 31, 2018. Other eligibility criteria include access to a telephone or mobile phone, not currently be pregnant or breastfeeding, have no significant co-morbidity that precludes participation (acute, life-threatening illness, and communication barriers such as tracheal tube or altered mental status). Those included in this analysis were those randomized into the trial who expressed interest in receiving a smoking cessation medication prescription at discharge. RESULTS: Two hundred fourteen patients were recommended a prescription by their smoking cessation counselor, 88 patients (41.12%) were approved a prescription at discharge. Out of those approved, 50.70 (14.05 SD) was the average age, 12.84 (8.47 SD) was the average number of cigarettes used per day, 47 patients (53.41%) were White, 49 patients (55.68%) were admitted through the emergency department, 55 patients (62.50%) had used smoking cessation medication in the past, 49 patients (55.68%) had used inpatient smoking cessation, 36 patients (40.91%) had Medicaid. A binary logistic regression determined to show insurance status (P = 0.042) and use of inpatient smoking cessation medication use (P < 0.001) as statistically significant predictors of receiving a prescription at discharge. CONCLUSION: It was determined that among the population recommended for medication, 41.12% actually received a prescription at discharge. The variables of “health insurance status” and “use of inpatient smoking cessation medication” demonstrated to be predictors of receiving a prescription. It is important to further study this as many patients rely on a prescription to afford these medications that are useful in a quit attempt.

BACKGROUND Despite a heightened appreciation for wellness in medicine, there exists little information specific to plastic surgery. The purpose of this research was to assess happiness within the field of plastic surgery. METHODS A cross-sectional study was conducted in July of 2017 by distributing an American Society of Plastic Surgeons sponsored survey to a random cohort of current practicing American Society of Plastic Surgeons members, residents and fellows. In addition, the same survey was sent to medical students applying to integrated plastic surgery residency. Total happiness scores (Subjective Happiness Scale) were averaged and compared between and within surveyed groups. RESULTS A total of 595 individuals completed surveys, including 287 practicing surgeons, 116 residents, 12 fellows, and 180 medical students. Differences in happiness scores between the groups were statistically significant (P < 0.01). For practicing physicians, happiness scores were significantly greater for those more than 20 years out from training (P < 0.01). Furthermore, a significantly positive correlation was found between practice expectations coming out of residency and happiness scores (Pearson correlation coefficient, 0.2; P < 0.01). CONCLUSIONS Despite the prevalence of burnout and mental health disorders associated with a career in medicine, plastic surgeons and trainees report high levels of happiness. Practicing plastic surgeons report increased happiness further out from training and when meeting practice expectations coming out of training. Otherwise, there were no significant differences in happiness between groups. Regarding sex, it is encouraging to report no significant sex discrepancies with happiness in a field where women still face significant adversity.

Early infant diagnosis (EID) involves age-specific tracking and testing of HIV-exposed infants during the first 18 months of life and rapid initiation of life-saving treatment for those infected. In Kenya, pre-2013 data estimate EID lost to follow-up (LTFU) at 39–65%, yet no study has documented LTFU rates and predictors throughout the EID cascade since Option B+ fundamentally changed services by placing all HIV-positive expectant mothers on lifelong treatment. Using an explanatory mixed-method design, we assessed LTFU rates and predictors among 870 mother–infant dyads enrolled in EID in six urban/peri-urban Kenyan government hospitals. Mothers completed baseline surveys, and dyads were tracked through EID. We selected 12 baseline variables and modeled odds of LTFU at 9 and 18 months using mixed logistic regression. Qualitative interviews were conducted with 61 mothers to assess barriers and facilitators to completing EID. Thematically coded transcripts were used to interpret quantitative predictors of LTFU. By the 18-month test, 145 dyads (22%) were LTFU, with three-quarters of LTFU occurring between 9- and 18-month tests. Odds of LTFU at 18 months decreased by 10% for each additional year of maternal age and by 66% with HIV status disclosure. Qualitative data revealed how disclosure facilitated essential social support for EID completion and how older mothers attributed maturity and life experience to successful engagement in care. Findings suggest LTFU rates in Kenya have declined, but gaps remain in ensuring universal coverage. Efforts to improve retention should focus on increasing support for younger mothers and those who have not disclosed their HIV status.

Tobacco quitlines are effective, and work best for callers who receive three or more counseling sessions. Clinical settings are adopting quitline referral as a method for providing cessation support but little is known regarding enrollment and engagement following these referrals. We used data from quitline fax-back reports to describe enrollment and treatment engagement of 878 hospitalized patients who smoke who were referred via secure email to quitline at discharge. We compared patient demographics, tobacco characteristics, and treatment engagement between those enrolled and not enrolled. We conducted chi-square and t-tests to determine which variables should be included in a logistic regression to determine predictors of quitline enrollment. We did not receive fax-back reports for 25% (n = 221) of referred patients; these were excluded from all but the intent-to-treat analysis. Among patients for whom we received reports, 20.4% enrolled and accepted at least one service from the quitline. Among the 79.6% (n = 523) of patients who smoke not enrolled, most (78.3%; n = 410) were classified by the quitline as unreachable. Age (p = .006), smoking within 30 min of waking (p = .005), and interest in quitting (p = .008) were significant predictors of quitline enrollment. Using an intent to treat analysis, 11.4% (n = 100) of all referred patients were enrolled and accepted a single or multi-call programs; 4.2% (n = 37) of all referred patients enrolled and accepted a multi-call counseling program. Quitlines are a pillar of U.S. tobacco treatment. For quitlines to fulfill their potential, quitlines and hospitals must identify effective strategies for reaching and treating referred patients who smoke. Quitlines are effective and are readily available to many in advanced economy countries. Treatment engagement appears to be a barrier to quitline participation as we found few patients who were referred to the quitline actually enrolled in care. Quitlines should consider adopting alternative methods for reaching patients who smoke. Future research is warranted to determine effective solutions to breakdowns in transitions of care.

Crowding and boarding are common issues facing emergency departments (EDs) in the USA. These issues have negative effects on efficiency, patient care, satisfaction and healthcare team well-being. Data from an audit of the admissions process at a large, urban, academic US ED demonstrated a lengthy process, exceeding national benchmarks in both length of stay and boarding of admitted patients.We performed a pre–post study between July 2019 and July 2021 focused on the first step of the admission process at our institution, the time to bed request. All patients admitted to an internal medicine (IM) floor team from the ED were included in the study. The primary outcome was the time from decision to admit by the emergency medicine physician to placement of the bed request order by the IM physician. Quality improvement (QI) occurred in three phases: an initial preintervention process and electronic health record change to better capture admission times, a primary intervention focused on process change and provider education and a second intervention focused on improvements to provider communication.During the study period, 25 183 patients were admitted to IM floor teams and met inclusion criteria. Prior to the primary intervention, the mean time from ED decision to admit to IM placement of the bed request order was 75.1 min. Postintervention, the mean time decreased to 39.7 min, a statistically significant improvement of 35.4 min (p value This QI project demonstrates the ability of interventions to reduce the time to admission bed request order, a key step in the overall admission process and a contributor to boarding at our institution. In making process changes, the team also reduced provider handoffs and improved provider communication.

BACKGROUND Nipple reconstruction has been linked to patient satisfaction; however, there is debate about the validity of these findings in autologous breast reconstruction patients. This study hypothesized that satisfaction would increase with nipple reconstruction following autologous breast reconstruction. METHODS A comparison study was performed of autologous breast reconstruction patients. Patients completed a survey that included BREAST-Q and nipple satisfaction measures. A chart review identified reconstructive details. RESULTS A total of 191 patients completed the survey (48 percent response rate), with an average age of 53.7 ± 10.0 years and follow-up time of 2.8 ± 1.5 years. Nipple-areola complex reconstruction was completed in 33 percent of patients (63 of 191). Nipple-areola complex tattoos were used most frequently [n = 37 (58 percent)], followed by local flaps [n = 10 (16 percent)], free nipple-areola complex grafts [n = 9 (14 percent)], and a combination of local flaps and tattoos [n = 7 (11 percent)]. In comparison to women who did not undergo nipple-areola complex reconstruction, women who underwent any type of nipple reconstruction had a statistically higher BREAST-Q score for Sexual Well-Being (60 ± 24 versus 50 ± 22; p = 0.01), Postoperative Satisfaction with Breasts (65 ± 11 versus 61 ± 12; p = 0.01), and Satisfaction with Surgeon (97 ± 6 versus 93 ± 16; p = 0.009). The average nipple satisfaction score was 74 ± 19. There were correlations between the nipple satisfaction score and BREAST-Q scores for Sexual Well-Being (r = 0.50; p < 0.001), Psychosocial Well-Being (r = 0.43; p < 0.001), and Postoperative Satisfaction with Breasts (r = 0.43; p < 0.001). CONCLUSION Reconstruction of the nipple-areola complex is an important part of autologous breast reconstruction, resulting in increased sexual well-being and satisfaction with reconstructed breasts.

We assessed the preliminary impact of the adapted HIV Infant Tracking System (HITSystem v2.0) intervention on prevention of mother-to-child transmission (PMTCT) outcomes using a matched cluster randomized design in two Kenyan government hospitals. Between November 2017 and June 2019, n = 157 pregnant women with HIV were enrolled and followed from their first PMTCT appointment until 12-weeks postpartum. Data from 135 women were analyzed (HITSystem 2.0: n = 53, standard of care (SOC): n = 82), excluding eight deaths, eight pregnancy losses, and six transfers/moves. The primary outcome, complete PMTCT retention, is an aggregate measure of attendance at all scheduled antenatal appointments, hospital-based delivery, and infant HIV-testing before 7-weeks postnatal. HITSystem 2.0 participants were more likely to receive complete PMTCT services compared to SOC (56.6% vs. 17.1% p

Purpose Autologous breast reconstruction with abdominally based free flaps has traditionally been associated with a longer hospital stay and higher initial cost relative to other reconstructive methods. One important component of this course is postoperative pain control. Thoracic epidural anesthesia is considered among the most effective methods for pain control in the immediate postoperative period following these procedures. Recently, our institution began using 4 quadrant transversus abdominis plane (TAP) blocks with liposomal bupivacaine. Encouraging trends were observed with utilization of TAP blocks; however, we sought to quantify this effect compared with that of thoracic epidural anesthesia. This study would contribute to a growing body of evidence supporting an enhanced recovery pathway for microvascular breast reconstruction. Method Thirty patients who underwent deep inferior epigastric artery perforator flap-based breast reconstruction from January 2016 to April 2017 were evaluated. Fifteen patients received thoracic epidural anesthesia, and 15 received 4 quadrant TAP blocks with liposomal bupivacaine. Opioid consumption was evaluated and compared for the first 3 days postoperatively. All opioids were converted to oral morphine equivalents (OMEs) for standardization. Day of discharge, day of Foley removal, and several traditionally opioid-related adverse effects were also recorded and compared. Result On postoperative days 0, 1, 2, and 3, opioid consumption among those given epidural anesthesia compared with those who received TAP blocks with liposomal bupivacaine was 34.9 versus 32.6 OMEs (P = 0.81), 98.9 versus 92.4 OMEs (P = 0.78), 59.7 versus 56.0 OMEs (P = 0.79), and 59.6 versus 24.5 OMEs (P = 0.005*), respectively. Total opioid consumption for the epidural group was 253.1 versus 205.4 OMEs for the TAP block group (P = 0.2743). Time until removal of Foley was 2.7 days for patients with an epidural and 2.1 days for those receiving TAP blocks (P = 0.0056*). Length of stay for those receiving epidural was 4.33 days compared with 3.53 days for those receiving TAP blocks (P = 0.0002*). Conclusion When using TAP blocks with liposomal bupivacaine, a statistically significant effect on postoperative day 3 and decreased opioid utilization overall were observed. Patients also had their Foley removed sooner and were discharged from the hospital earlier.

BACKGROUND Current rates of opioid prescribing have deleterious consequences on both patient and societal levels. This study aims to evaluate responsible opioid prescribing and predictors of opioid consumption in immediate implant-based breast reconstruction. METHODS Patients undergoing consultation for immediate, implant-based breast reconstruction were enrolled in a prospective, cohort survey study. A survey was administered at the preoperative and postoperative appointment to collect data on pain expectations and opioid use. A medical record review was performed. RESULTS Of 100 enrolled patients, 97 (97.0 percent) underwent surgery and 85 (85.0 percent) completed the postoperative survey. Preoperatively, 27 patients (27.0 percent) had a history of a chronic pain syndrome, 34 (34.0 percent) had a history of a mental health comorbidity, and nine (9.0 percent) had a history of active preoperative opioid use. A total of 85 tissue expander (87.6 percent) and 12 direct-to-implant (12.4 percent) reconstructions were completed. Patients were prescribed an average of 36.0 5-mg oxycodone tablets postoperatively. Patients reported consuming an average of 20.6 tablets, or 57.0 percent of the average prescription amount. The majority of patients (75.3 percent) reported taking an opioid less than once per day at the time of survey completion, and 24 patients (28.2 percent) reported that they did not use any opioids postoperatively. Preoperative opioid use (p = 0.004), inpatient opioid consumption (p < 0.0001), and patient-reported anxiety related to pain control (p < 0.05) were predictors of opioid consumption. CONCLUSIONS Patients undergoing mastectomy and implant-based breast reconstruction are prescribed nearly twice as many opioid tablets as consumed, and one in three patients report not using any opioids postoperatively. Clinical factors may help guide prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Author(s): Cannon, Chad M.; Miller, Ross T.; Grow, Krista L.; Purcell, Seth; Nazir, Niaman | Abstract: Introduction: While numerous studies have found emergency department (ED) lactate levels to be associated with increased in-hospital mortality, little information is available on the role age plays in this association. This study investigates whether age is a necessary variable to consider when using lactate levels as a marker of prognosis and a guide for management decisions in the ED.Methods: This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A total of 13,506 lactate levels were obtained over a 4.5-year period. All adult patients who had a lactate level obtained by the treating provider in the ED were screened for inclusion. The main outcome measure was in-hospital mortality using age-adjusted cohorts and expanded lactate thresholds with secondary outcomes comparing mortality based on the primary clinical impression.Results: Of the 8796 patients in this analysis, there were 474 (5.4%) deaths. Mortality rates increased with both increasing lactate levels and increasing age. For all ages, mortality rates increased from 2.8% in the less than 2.0 millimoles per liter (mmol/L) lactate level, to 5.6% in the 2.0-2.9 mmol/L lactate level, to 8.0% in the 3.0-3.9 mmol/L lactate level, to 13.9% in the 4.0-4.9 mmol/L lactate level, to 13.7% in the 5.0-5.9 mmol/L lactate level, and to 39.1% in the 6.0 mmol/L or greater lactate level (p l0.0001). Survivors, regardless of age, had a mean lactate level l2.0 whereas non-survivors had mean lactate levels of 6.5, 4.5, and 3.7 mmol/L for age cohorts 18-39, 40-64, and ≥ 65 years, respectively.Conclusion: Our findings suggest that although lactate levels can be used as a prognostic tool to risk stratify ED patients, the traditional lactate level thresholds may need to be adjusted to account for varying risk based on age and clinical impressions.

Although there has been a recent focus on decreasing opioid prescribing through alternative pain medication protocols, the patient's perception of pain related to breast reconstructive surgeries has not been well described. We sought to evaluate patient perception of pain control as it influences opioid use. We hypothesize that modifiable factors may influence patterns in pain perception and postoperative opioid use. Patients undergoing consultation for mastectomy with immediate, implant-based breast reconstruction were enrolled in a prospective, cohort survey study. A survey was administered at preoperative and postoperative appointments to collect data on pain expectations and pain control. Of 100 patients enrolled, 85% completed the postoperative survey. Over half of patients (52%) reported feeling anxious about pain control after surgery. Patients with preoperative opioid use were more likely to expect complete relief of pain postoperatively (P = .038). Patients with psychiatric comorbidity were more likely to report feeling anxious about postoperative pain (P = .012; 70% vs 42%; OR 3.0 CI 1.2-7.4). Patients who reported feeling anxious about pain control preoperatively were more likely to report trying opioids (P = .047; 67% vs 44%; OR 2.5 CI 1.0-6.1) and benzodiazepines (P = .020; 80% vs 56%; OR 3.0 CI 1.2-8.0) postoperatively. Anxiety related to pain control is common and results in an increased likelihood of trying opioid and benzodiazepine medications postoperatively. This presents an opportunity to educate patients preoperatively by addressing anxiety related to pain control to decrease controlled substance use.

The HIV Infant Tracking System (HITSystem) is a web-based intervention linking providers of early infant diagnosis, laboratory technicians, and mothers and infants to improve outcomes for HIV-exposed infants. We aimed to evaluate the efficacy of the HITSystem on key outcomes of early infant diagnosis.We did a cluster-randomised trial at six hospitals in Kenya, which were matched on geographic region, resource level, and volume of patients (high, medium, and low). We randomly allocated hospitals within a matched pair to either the HITSystem (intervention; n=3) or standard of care (control; n=3). A random number generator was used to assign clusters. Investigators were unaware of the randomisation process. Eligible participants were mothers aged 18 years or older with an infant younger than 24 weeks presenting for their first early infant diagnosis appointment. The primary outcome was complete early infant diagnosis retention, which was defined as receipt of all indicated age-specific interventions until 18 months post partum (for HIV-negative infants) or antiretroviral therapy initiation (for HIV-positive infants). Analysis was per protocol in all randomised pairs judged eligible, excluding infant deaths and those who moved or were transferred to another health facility. Modified intention-to-treat sensitivity analyses judged all infant deaths and transfers as incomplete early infant diagnosis retention. Separate multivariable logistic regression analyses were done with intervention group, hospital volume, and significant covariates as fixed effects. This trial is registered with ClinicalTrials.gov, number NCT02072603; the trial has been completed.Between Feb 16, 2014, and Dec 31, 2015, 895 mother-infant pairs were enrolled. Of these, 87 were judged ineligible for analysis, 26 infants died, and 92 pairs moved or were transferred to another health facility. Thus, data from 690 mother-infant pairs were analysed, of whom 392 were allocated to the HITSystem and 298 to standard of care. Mother-infant pairs were followed up to Sept 30, 2017. Infants diagnosed as HIV-positive were followed up for a median of 2·1 months (IQR 1·6-4·8) and HIV-negative infants were followed up for a median of 17·0 months (IQR 16·6-17·6). Infants enrolled in the HITSystem were significantly more likely to receive complete early infant diagnosis services compared with those assigned standard of care (334 of 392 [85%] vs 180 of 298 [60%]; adjusted odds ratio [OR] 3·7, 95% CI 2·5-5·5; p0·0001). No intervention effect was recorded at high-volume hospitals, but strong effects were seen at medium-volume and low-volume hospitals. Modified intention-to-treat analyses for complete early infant diagnosis were also significant (334 of 474 [70%] vs 180 of 334 [54%]; adjusted OR 2·0, 95% CI 1·4-2·7; p0·0001). No adverse events related to study participation were reported.The HITSystem intervention is effective and feasible to implement in low-resource settings. The HITSystem algorithms have been modified to include HIV testing at birth, and an adapted HITSystem 2.0 version is supporting HIV-positive pregnant women to prevent perinatal transmission and optimise maternal and infant outcomes.National Institute of Child Health and Human Development.

OBJECTIVES: Dyspareunia and sexual dysfunction are estimated to affect up to 22% and 43% of women respectively. There is concern that these statistics do not depict the true prevalence and that these conditions are frequently undiagnosed and untreated. By 2060, Latinos will make up 30% of the total population in the United States. As our patient population becomes more diverse, we need to ensure that our healthcare practices accommodate the changes. METHODS: We surveyed a convenience sample of 107 English and 71 Spanish-speaking women, aged 18–45, at university affiliated clinics to identify the prevalence of dyspareunia and sexual dysfunction within our community. Additionally, we wanted to identify the rate that clinicians discuss painful sex with patients to identify if language impacted communication. The surveys collected data on subjective reporting of pain with sex and objective identification of sexual dysfunction with the Female Sexual Function Index (FSFI). Additional questions identified if subjects discussed pain with their clinician. These questions were analyzed between languages across all domains. RESULTS: A greater prevalence of both dyspareunia and sexual dysfunction were measured in our study population compared to prior reports (37.79% and 54.71% respectively). Spanish-speaking women had significantly lower self-reported dyspareunia (28.99%), but scored significantly lower on the FSFI, qualifying for sexual dysfunction (63.24%). Spanish-speakers discussed painful sex significantly less compared to the English cohort, but the overall discussion rate was only 17.26%. CONCLUSIONS: This pilot data demonstrates a need for further research on language as a barrier to communication about sexual function in clinic.

Objectives/hypothesis New advances in osseous microvascular mandibular rigid fixation are being employed at many institutions. These include standardized prebent/preformed reconstruction plates as well as computer-aided design/computer-aided manufacturing (CAD/CAM) custom plates that are patient specific. Our goal was to assess and compare the outcomes of both of these new technologies when utilized for mandibular microvascular reconstruction. Study design Retrospective chart review. Methods Subjects were categorized into two groups according to their mandibular rigid fixation technique: group 1 = prebent/preformed plates and group 2 = CAD/CAM custom plates. Primary outcome measures were 1) perioperative complications (defined as deep tissue infection, wound dehiscence resulting in bone exposure, and/or plate exposure) and 2) reoperation rates for mandibular hardware failure/explantation. Statistical analysis consisted of χ2 , Fisher exact test, and multivariable regression models. Results A total of 142 subjects underwent microvascular mandibular reconstruction in a 6-year period. Eighty-nine subjects utilized prebent/preformed plates, and 53 employed CAD/CAM custom plates. Perioperative complications occurred in 32 of 89 (35.9%) subjects with prebent/preformed plates and 11 of 53 (20.7%) subjects using CAD/CAM custom plates. Reoperation requiring hardware explantation occurred in 18 of 89 (20.2%) subjects and three of 53 (5.6%) using CAD/CAM custom plates. Statistical comparison of perioperative complications between the two groups approached significance (P = .0556), and the rate of reoperation was significant favoring CAD/CAM implants (P = .0180). Conclusions In our experience, CAD/CAM custom plates utilized for rigid fixation during microvascular mandibular reconstruction demonstrated fewer complications and statistically lower reoperation rates when compared with prebent/preformed plates. Level of evidence 2c Laryngoscope, 129:1081-1086, 2019.

Quitlines provide evidence-based tobacco treatment and multiple calls yield higher quit rates. This study aimed to identify subgroups of smokers with greater quitline engagement following referral during hospitalization. Data were from a randomized clinical trial assessing the effectiveness of fax referral (referral faxed to proactive quitline) versus warm handoff (patient connected to quitline at bedside) (n=1,054). Classification and regression trees (CART) analyses evaluated individual and treatment/health system-related variables and their interactions. Among all participants, warm handoff, higher ratings of the tobacco treatment care transition, and being older predicted completing more quitline calls. Among patients enrolled in the quitline, higher transition of care ratings, being older, and use of cessation medication post-discharge predicted completing more calls. Three of the four factors influencing engagement were characteristics of treatment within the hospital (quality of tobacco treatment care transition and referral method) and therapy (use of cessation medications), suggesting potential targets to increase quitline engagement post-discharge.

Introduction The prevalence of smoking among people living with HIV/AIDS (PLWHA) remains higher than the general population. Life expectancy among PLWHA has increased over the past decade, however, PLWHA who smoke will die younger than their non-smoking peers. The primary aim of this pilot study was to examine the effects of warm handoff versus fax referral to the quitline for smoking cessation among hospitalized smokers living with HIV/AIDS. Methods 25 smokers with a diagnosis of HIV/AIDS hospitalized at a Midwestern academic medical center in 2012–2013 (19 male; mean age = 47.7; 48% African-American) were identified, approached, and randomized to one of two treatment arms. At the bedside for patients in warm handoff, staff telephoned the quitline for on-the-spot enrollment and counseling. Participants randomized to fax were fax-referred to the quitline on the day of discharge. The quitline provided continued outpatient counseling to participants in both conditions. The main outcome was verified tobacco abstinence at 6-months post randomization. Results Enrollment and participation in quitline counseling was high among both warm handoff (100%) and fax-referred (71.4%) PLWHA participants. Nearly all completed follow up for outcome data collection at 6 months. Verified abstinent rates were 45.5% in warm handoff versus 14.3% in fax referral at 6 months (not significant). Conclusions Hospitalized smokers living with HIV/AIDS were highly engaged in quitline services. Warm handoff seems a promising intervention for hospitalized PLWHA that requires further exploration. Clinical Trials Registration NCT01305928 .

The purpose of this study was to examine knowledge, awareness, and support for campus smoke-free policies.1,256 American Indian tribal college students from three tribal colleges in the Midwest and Northern Plains.Data are from an observational cross-sectional study of American Indian tribal college students, collected through a web-based survey.Only 40% of tribal college students reported not being exposed to second hand smoke in the past 7 days. A majority of nonsmokers (66%) agreed or strongly agreed with having a smoke-free campus, while 34.2% of smokers also agreed or strongly agreed. Overall, more than a third (36.6%) of tribal college students were not aware of their campus smoking policies.Tribal campuses serving American Indian students have been much slower in adopting smoke-free campus policies. Our findings show that tribal college students would support a smoke-free campus policy.

Background Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine (REMS) Score for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the “Mechanism, Glasgow Coma Scale, Age and Arterial Pressure” (MGAP) score, and the Shock Index (SI) score. Methods The two-part study design involved both a modification step and a validation step. The first step incorporated a retrospective analysis of a local trauma database (3680 patients) where three components of REMS were modified to more accurately represent the trauma population. Using clinical judgment and goodness-of-fit tests, systolic blood pressure was substituted for mean arterial pressure, the weighting of age was reduced, and the weighting of Glasgow Coma Scale was increased. The second part comprised validating the new modified REMS (mREMS) score retrospectively on a U.S. National Trauma Databank (NTDB) that included 429,711 patients admitted with trauma in 2012. The discriminate power of mREMS was compared to other trauma scores using the area under the receiver operating characteristic (AUC) curve. Results Overall the mREMS score with an AUC of 0.967 (95% CI: 0.963–0.971) was demonstrated to be higher than RTS (AUC 0.959 [95% CI: 0.955–0.964]), ISS (AUC 0.780 [95% CI 0.770–0.791]), MGAP (AUC 0.964 [95% CI: 0.959–0.968]), and SI (AUC 0.670 [95% CI: 0.650–0.690]) in predicting in-hospital mortality on the NTDB. Conclusion In the trauma population, mREMS is an accurate predictor of in-hospital mortality, outperforming other used scores. Simple and objective, mREMS may hold value in the pre-hospital and emergency department setting in order to guide trauma team responses.

INTRODUCTION: Prevalence of cigarette smoking is highest among American Indians, yet few culturally appropriate smoking cessation programs have yet been developed and tested for multi-tribal American Indian adult populations. This study examined implementation of the All Nations Breath of Life culturally tailored smoking cessation program in multi-tribal urban and suburban American Indian communities in seven locations across five states (N = 312). METHODS: This single-arm study used community-based participatory research to conduct a 12-week intervention whose primary purpose was to curb commercial tobacco use among American Indians. Participants were followed through month 6 in person and month 12 via telephone. The primary outcome was continuous abstinence from recreational cigarette smoking at 6 months post-baseline, verified through voluntary provision of salivary cotinine levels. RESULTS: At program completion (12 weeks post-baseline), 53.3% of program completers remained abstinent; labeling those lost to follow-up as smokers resulted in a 41.4% quit rate. At 6 months post-baseline (primary endpoint), 31.1% of retained participants quit smoking (p < .0001 compared to the highest quit rates among multi-tribal populations reported in the literature, 7%); final quit rate was 22.1% labeling those lost to follow-up as smokers (p = .002). Retention rate at endpoint was 71.2%. 12-month follow-up was attempted with all participants and had a retention rate of 49.0%. Of those participants reached, 34.0% were smoke-free. CONCLUSIONS: All Nations Breath of Life shows promise as a smoking cessation program for multi-tribal urban American Indian communities. It can be successfully implemented in a variety of urban settings. IMPLICATIONS: This is the first large feasibility study of a culturally tailored smoking cessation program for American Indians with good cessation and retention rates in a multi-tribal urban American Indian population. It shows that All Nations Breath of Life can be implemented in multiple urban settings across five states. To our knowledge, this is the first program of its kind to be implemented across multiple heterogeneous urban locations and to include salivary cotinine testing for verification of self-report data across these locations.

BackgroundTesting infants at birth and with more efficient point of care (POC) HIV diagnostic can streamline EID and expedite infant ART initiation. We evaluated the implementation of at birth and 6-week POC testing to assess the effectiveness and feasibility when implemented by existing hospital staff in Kenya.MethodsFour government hospitals were randomly assigned to receive a GeneXpert HIV-1 Qual (n = 2) or Alere m-PIMA (n = 2) machine for POC testing. All HIV-exposed infants enrolled were eligible to receive POC testing at birth and 6-weeks of age. The primary outcome was repeat POC testing, defined as testing both at birth and 6-weeks of age. Secondary outcomes included predictors of repeat POC testing, POC efficiency (turnaround times of key services), and operations (failed POC results, missed opportunities).ResultsOf 626 enrolled infants, 309 (49.4%) received repeat POC testing, 115 (18.4%) were lost to follow up after an at-birth test, 120 (19.2%) received POC testing at 6-weeks only, 80 (12.8%) received no POC testing, and 2 (0.3%) received delayed POC testing (>12 weeks of age). Three (0.4%) were identified as HIV-positive. Of the total 853 POC tests run at birth (n = 424) or 6-weeks (n = 429), 806 (94.5%) had a valid result documented and 792 (98.3%) results had documented maternal notification. Mean time from sample collection to notification was 1.08 days, with 751 (94.8%) notifications on the same day as sample collection. Machine error rates at birth and 6-weeks were 8.5% and 2.5%, respectively. A total of 198 infants presented for care (48 at birth; 150 at 6-weeks) without receiving a POC test, representing missed opportunities for testing.DiscussionAt birth POC testing can streamline infant HIV diagnosis, expedite ART initiation and can be implemented by existing hospital staff. However, maternal disengagement and missed opportunities for testing must be addressed to realize the full benefits of at birth POC testing.

Background Invasive lobular carcinoma (ILC) has unique histologic growth pattern. Few studies have focused on the value of breast magnetic resonance imaging (MRI) specifically for ILC. We hypothesized that MRI adds value to the diagnostic workup in ILC by better defining the extent of disease and identifying additional foci of malignancy, which can change the surgical plan. Materials and methods This was a single-institution retrospective review of women diagnosed with ILC from 1/2012 to 7/2019 who underwent preoperative MRI. Patient, tumor characteristics, and initial surgical plan were reviewed. MRI had added value if ILC size correlated best to final pathologic size or if additional malignancy was identified. MRI was considered harmful if additional biopsies were benign or if the size was overestimated. Results ILC was identified in 166 breasts in 165 women. Original surgical plan was for lumpectomy in 86 (52%), mastectomy in 49 (30%), and undecided in 31 (18%). MRI changed the plan in 25 (19%) with 24 (96%) changing from lumpectomy to mastectomy. Additional biopsy was performed in 28% after MRI, the majority (n = 41, 72%) were benign or high risk and 16 (28%) identified additional malignancy. MRI was not a better size estimate than mammogram/ultrasound. Re-excision rate after lumpectomy was 6.8% (5/73). MRI added value in 48 (28.9%) and was harmful in 48 (28.9%). Conclusions Using breast MRI in the diagnostic workup of ILC has both positive and negative implications on surgical treatment planning. A shared decision-making conversation is warranted before proceeding with MRI to maximize value and minimize harms associated with this diagnostic tool.

American Indian (AI) smokeless tobacco use rates are the highest of all racial/ethnic groups within the United States. Despite this, no effective cessation program currently exists that acknowledges the cultural significance of tobacco among many American Indian tribal nations. Participants were smokeless tobacco users, over 18 years of age, and were recruited through community partners. We modified the All Nations Snuff Out Smokeless Tobacco group-based program to be delivered as a one-time education session intervention. This was delivered to 80 participants and follow-up data was collected by self-report at 6-months. The mean age of participants was 35 and most were male (70%). A majority (69%) grew up on a AI reservation; the mean age of first smokeless tobacco use was 16 years of age. Of program completers reached for 6-month post baseline, 46% reported 0 days of SLT use; 13.5% of participants reduced; while 36% reported continued daily use. In intention to treat analysis those lost to follow-up are considered current users, the quit rate was 12.5% and among those who were still using, 4.0% reduced their use. In this study, a one-time education session intervention was effective for those who prefer an individual based approach to quitting SLT use. Follow up strategies to increase participant retention at 6-months should be explored.

Underreporting of concussions and concussion-like symptoms in athletes continues to be a serious medical concern and research focus. Despite mounting worry, little evidence exists examining incidence of underreporting and documenting characteristics of head injury in female athletes participating in high school sports. This study examined the self-reporting behaviors of female high school athletes. Seventy-seven athletes participated, representing 14 high school sports. Nearly half of the athletes (31 participants) reported a suspected concussion, with 10 of the 31 athletes refraining from reporting symptoms to training staff after injury. Only 66% reported receiving concussion education. Concussion education appeared to have no relationship with diagnosed concussion rates in athletes, removing athletes from play, or follow-up medical care after injury. In conclusion, female high school athletes underreport signs and symptoms of concussions. Concussion education should occur at higher rates among female athletes to influence reporting behaviors.

The use of cannabis is currently increasing according to U.S. Department of Health and Human Services (HHS). Surprisingly, cannabis use among burn patients is poorly reported in literature. In this study, rates of cannabis use in burn patients are compared with general population. Data from the National Burn Repository (NBR) were used to investigate incidence, demographics, and outcomes in relation to use of cannabis as evidenced by urine drug screen (UDS). Thousands of patients from the NBR from 2002 to 2011 were included in this retrospective study. Inclusion criteria were patients older than 12 years of age who received a drug screen. Data points analyzed were patients' age, sex, UDS status, mechanism of burn injury, total body surface area, length of stay, ICU days, and insurance characteristics. Incidence of cannabis use in burn patients from the NBR was compared against national general population rates (gathered by Health and Human Services) using chi-square tests. Additionally, the burn patient population was analyzed using bivariate analysis and t-tests to find differences in the characteristics of these patients as well as differences in outcomes. Seventeen thousand eighty out of over 112,000 patients from NBR had information available for UDS. The incidence of cannabis use is increasing among the general population, but the rate is increasing more quickly among patients in the burn patient population (P = .0022). In 2002, 6.0% of patients in burn units had cannabis+ UDS, which was comparable with national incidence of 6.2%. By 2011, 27.0% of burn patients tested cannabis+ while national incidence of cannabis use was 7.0%. Patients who test cannabis+ are generally men (80.1%, P.0001) and are younger on average (35 years old vs 42, P.0001). The most common mechanisms of injury among patients who test cannabis+ or cannabis- are similar. Flame injury makes up60% of injuries, followed by scalds that are15%. In comparing cannabis+/- patients, cannabis+ patients are more likely to be uninsured (25.2% vs 17.26%, P.0001). Finally, patients who test cannabis+ have larger burns (TBSA% of 12.94 vs 10.98, P.0001), have a longer length of stay (13.31 days vs 12.6, P = .16), spend more days in the ICU (7.84 vs 6.39, P = .0006), and have more operations (2.78 vs 2.05, P.0001). The rate patients testing positive for cannabis in burn units is growing quickly. These patients are younger and are less likely to be insured. These patients also have larger burns, spend more time in ICUs, and have a greater number of operations. The increasing use of cannabis, as expected from legalization of cannabis in multiple states, among burn patient population may lead to increased burden on already tenuous health care resources.

Background Most health care providers do not treat tobacco dependence routinely. This may in part be due to the treatment “default.” Current treatment guidelines recommend that providers (1) ask patients if they are willing to quit and (2) provide cessation-focused medications and counseling only to smokers who state that they are willing to quit. The default is that patients have to “opt in” to receive cessation assistance: providers ask smokers if they are willing to quit, and only offer medications and cessation support to those who say “yes.” This drastically limits the reach of cessation services because, at any given encounter, only one in three smokers say that they are ready to quit. The objective of this study is to determine the impact of providing all smokers with tobacco-cessation treatment unless they refuse it (OPT OUT) versus current practice—screening for readiness and only offering treatment to smokers who say they are ready to quit (OPT IN). Methods This individually randomized clinical trial is conducted in a tertiary-care hospital. We will conduct the trial among up to 1000 randomly selected hospitalized smokers to determine the population impact of changing the treatment default, identify mediators of outcome, and determine the cost-effectiveness of this new, highly proactive approach. This is a population-based study that targets an endpoint of vital interest; applies minimal eligibility criteria to broaden generalizability; and utilizes hospital staff for interventions to ensure long-term sustainability. The study employs delayed consent and an innovative Bayesian adaptive design to evaluate a major shift in our approach to care. If effective, this change would expand the reach of tobacco-cessation treatment from 30% to 100% of smokers. Discussion Regardless of outcome, the trial will provide a model of how to alter and evaluate the impact of health care defaults. If OPT OUT proves to be more effective, it will expand the population eligible for cessation treatment by over 300%. It will also simplify the tobacco-cessation treatment algorithm, and relieve busy health care providers of the burden of evaluating readiness to quit. Trial registration Clinical Trials Registration, ID: NCT02721082. Registered on 22 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2119-9) contains supplementary material, which is available to authorized users.

The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition-related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.

Background— This trial tested the effects of multidisciplinary group clinic appointments on the primary outcome of time to first heart failure (HF) rehospitalization or death. Methods and Results— HF patients (n=198) were randomly assigned to standard care or standard care plus multidisciplinary group clinics. The group intervention consisted of 4 weekly clinic appointments and 1 booster clinic at month 6, where multidisciplinary professionals engaged patients in HF self-management skills. Data were collected prospectively for 12 months beginning after completion of the first 4 group clinic appointments (2 months post randomization). The intervention was associated with greater adherence to recommended vasodilators ( P =0.04). The primary outcome (first HF-related hospitalization or death) was experienced by 22 (24%) in the intervention group and 30 (28%) in standard care. The total HF-related hospitalizations, including repeat hospitalizations after the first time, were 28 in the intervention group and 45 among those receiving standard care. The effects of treatment on rehospitalization varied significantly over time. From 2 to 7 months post randomization, there was a significantly longer hospitalization-free time in the intervention group (Cox proportional hazard ratio=0.45 (95% confidence interval, 0.21–0.98; P =0.04). No significant difference between groups was found from month 8 to 12 (hazard ratio=1.7; 95% confidence interval, 0.7–4.1). Conclusions— Multidisciplinary group clinic appointments were associated with greater adherence to selected HF medications and longer hospitalization-free survival during the time that the intervention was underway. Larger studies will be needed to confirm the benefits seen in this trial and identify methods to sustain these benefits. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00439842.

In rural America cigarette smoking is prevalent, few cessation services are available, and healthcare providers lack the time and resources to help smokers quit. This paper describes the design and participant characteristics of Connect2Quit (C2Q), a randomized control trial (RCT) that tests the effectiveness and cost-effectiveness of integrated telemedicine counseling delivered by 2-way webcams mounted on desktop computers in participant's physician office examining rooms (ITM) versus quitline counseling delivered by telephone in participant's homes (Phone) for helping rural smokers quit.C2Q was implemented in twenty primary care and safety net clinics. Integrated telemedicine consisted of real-time video counseling, delivered to patients in their primary care physician's (PCP) office. Phone counseling, was delivered to patients in their homes. All participants received educational materials and guidance in selecting cessation medications.The 566 participants were predominantly Caucasian (92%); 9% were Latino. Most (65%) earned200% of Federal Poverty Level. One out of three lacked home internet access, 40% were not comfortable using computers, and only 4% had been seen by a doctor via telemedicine in the past. Hypertension, chronic lung disease, and diabetes were highly prevalent. Participants smoked nearly a pack a day and were highly motivated to quit.C2Q is reaching a rural low-income population, with comorbid chronic diseases, that would benefit greatly from quitting smoking. ITM is a good delivery model, which integrates care by holding counseling sessions in the patient's PCP office and keeps the primary care team updated on patients' progress.NCT00843505.

Introduction American Indians (AI) have the highest smoking rates of any racial/ethnic group in the U.S. and have more difficulty quitting smoking. Little is known about the smoking characteristics of AI smokers. The present study compared the demographic and smoking characteristics of light (≤ 10 cigarettes per day; N = 206) and moderate/heavy (11 + cigarettes per day; N = 86) AI smokers participating in a cross-sectional survey about smoking and health. Methods Multiple methods were used to recruit participants in attendance at powwows, health and career fairs, and conferences. A total of 998 AI (76% cooperation rate) completed a survey assessing general health, sociodemographics, traditional and commercial tobacco use, knowledge and attitudes related to cancer, source of health information and care and other health-related behaviors. Results AI light smokers were younger and less likely to be married or living with a partner compared to moderate/heavy smokers. AI light smokers were less dependent on smoking and more likely to have home smoking restrictions. There were no differences with respect to number of quit attempts in the past year or the average length of their most recent quit attempt by light vs. moderate/heavy smoking. In addition, a similar proportion of light and heavy smokers reported using tobacco for traditional purposes such as ceremonial, spiritual and prayer. Conclusions These findings highlight important differences between AI light and heavier smokers. Differences related to smoking characteristics such as level of dependence and home smoking restrictions have important implications for the treatment of AI smokers.

Fatalistic beliefs about cancer prevention can be a significant deterrent to one's likelihood of engaging in cancer prevention behaviors. Lower education and less access to cancer information among rural residents may influence their level of cancer fatalism. The purpose of this study was to examine rural-urban differences in fatalistic beliefs about cancer prevention and cancer information sources using data from the 2007 Health Information National Trends Survey (n = 1,482 rural and 6,192 urban residents). Results showed that rural residents were more likely to endorse multiple fatalistic beliefs about cancer prevention than urban residents even after controlling for other significant demographic correlates. Urban residents were more likely to use the internet as their primary cancer information source, whereas rural residents were more likely to rely on print material and healthcare providers. Future educational work to communicate relevant and accurate cancer prevention information to rural residents should consider not only information access but also rural culture and fatalistic perspectives.

Deformational plagiocephaly (DP) in infants has been associated with developmental delay that can last until adolescence. Despite this association and a 5-fold increase in incidence of DP over the past 2 decades, there are currently no guidelines regarding screening for developmental delay or identification of which infants with DP are at the greatest risk of delay. A prospective, nonrandomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression. Twenty-seven infants, ages 4.0 to 11.0 months (mean = 6.61 months) diagnosed with DP were studied. Developmental delay was observed on the composite language (n = 3 of 27, 11%), and composite motor (n = 5 of 23, 22%) scales, but not the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R = 0.058, P = 0.238; composite language R = 0.03, P = 0.399; composite motor R = 0.0195, P = 0.536). This study demonstrates that severity of cranial deformity cannot be used to predict presence or degree of developmental delay. Craniofacial surgeons should be aware of this risk and consider developmental screening based on clinical suspicion.

Introduction Few hospitals treat patients' tobacco dependence. To be effective, hospital-initiated cessation interventions must provide at least 1 month of supportive contact post-discharge. Study design Individually randomized clinical trial. Recruitment commenced July 2011; analyses were conducted October 2014–June 2015. Setting/participants The study was conducted in two large Midwestern hospitals. Participants included smokers who were aged ≥18 years, planned to stay quit after discharge, and spoke English or Spanish. Intervention Hospital-based cessation counselors delivered the intervention. For patients randomized to warm handoff, staff immediately called the quitline from the bedside and handed the phone to participants for enrollment and counseling. Participants randomized to fax were referred on the day of hospital discharge. Main outcome measures Outcomes at 6 months included quitline enrollment/adherence, medication use, biochemically verified cessation, and cost effectiveness. Results Significantly more warm handoff than fax participants enrolled in quitline (99.6% vs 59.6%; relative risk, 1.67; 95% CI=1.65, 1.68). One in four (25.4% warm handoff, 25.3% fax) were verified to be abstinent at 6-month follow-up; this did not differ significantly between groups (relative risk, 1.02; 95% CI=0.82, 1.24). Cessation medication use in the hospital and receipt of a prescription for medication at discharge did not differ between groups; however, significantly more fax participants reported using cessation medication post-discharge (32% vs 25%, p =0.01). The average incremental cost-effectiveness ratio of enrolling participants into warm handoff was $0.14. Hospital-borne costs were significantly lower in warm handoff than in fax ($5.77 vs $9.41, p Conclusions One in four inpatient smokers referred to quitline by either method were abstinent at 6 months post-discharge. Among motivated smokers, fax referral and warm handoff are efficient and comparatively effective ways to link smokers with evidence-based care. For hospitals, warm handoff is a less expensive and more effective method for enrolling smokers in quitline services.

Introduction In its fiscal year 2015 final rule, the Centers for Medicare & Medicaid Services (CMS) required reporting of tobacco treatment quality measures as part of the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS). This pre-intervention, post-intervention policy analysis evaluates the impact of that policy at a large academic medical center that opted to improve performance as it implemented reporting measures. Methods Electronic medical record data were collected retrospectively for all adult (≥18 years) inpatient psychiatric admissions from January 1, 2014 to December 31, 2015. Data from admissions were analyzed to determine changes in the provision of tobacco treatment including the proportions of patients screened for tobacco use, receiving tobacco cessation counseling, and receiving tobacco cessation medication(s) using a chi-square test. Covariate analysis of treatment differences based on psychiatric diagnosis was analyzed using Cochran-Mantel-Haenszel and Breslow-Day test. Results Post-policy screening for admissions increased significantly (85% vs. 97%; p < .001). Referral to cessation counseling increased 18-fold (4% vs. 74%; p < .001). Receipt of Counselling (8% vs. 67%; p < .001) and referral for cessation medication (32% vs. 68%; p < .001) also increased dramatically. Though statistically non-significant, the number of tobacco users who actually received medications increased markedly between 2014 and 2015, 24% versus 35%. Gains in screening, referral, and treatment did not differ by psychiatric diagnosis. Conclusions The Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program resulted in a 10-fold increase in the number of smokers who received inpatient tobacco treatment. Should CMS link prospective payment to performance, it could have a major impact on quality of care for tobacco dependence. Implications This is the first study to examine the implementation and impact of new 2015 IPFQR program tobacco measures. This study may illustrate the potential effect that performance based penalties can have should facilities be required to do more than simply report on these tobacco measures. This study exemplifies the impact these new reporting measures can have when psychiatric facilities move beyond letter of the policy, to continually assess organizational performance and implement changes to improve treatment delivery.

BACKGROUND Rib fractures are common in trauma admissions and are associated with an increased risk of pulmonary complications, intensive care unit admissions, and mortality. Providing adequate pain control in patients with multiple rib fractures decreases the risk of adverse events. Thoracic epidural analgesia is currently the preferred method for pain control. This study compared outcomes in patients with multiple acute rib fractures treated with posterior paramedian subrhomboidal (PoPS) analgesia versus thoracic epidural analgesia (TEA). METHODS This prospective study included 30 patients with three or more acute rib fractures admitted to a Level I trauma center. Thoracic epidural analgesia or PoPS catheters were placed, and local anesthesia was infused. Data were collected including patients' pain level, adjunct morphine equivalent use, adverse events, length of stay, lung volumes, and discharge disposition. Nonparametric tests were used and two-sided p < 0.05 were considered statistically significant. RESULTS Nineteen (63%) of 30 patients received TEA and 11 (37%) of 30 patients received PoPS. Pain rating was lower in the PoPS group (2.5 vs. 5; p = 0.03) after initial placement. Overall, there was no other statistically significant difference in pain control or use of oral morphine adjuncts between the groups. Hypotension occurred in eight patients, 75% with TEA and only 25% with PoPS. No difference was found in adverse events, length of stay, lung volumes, or discharge disposition. CONCLUSION In patients with rib fractures, PoPS analgesia may provide pain control equivalent to TEA while being less invasive and more readily placed by a variety of hospital staff. This pilot study is limited by its small sample size, and therefore additional studies are needed to prove equivalence of PoPS compared to TEA. LEVEL OF EVIDENCE Therapeutic study, level IV.

INTRODUCTION Measuring adherence to smoking cessation pharmacotherapy is important to evaluating its effectiveness. Blood levels are considered the most accurate measure of adherence but are invasive and costly. Pill counts and self-report are more practical, but little is known about their relationship to blood levels. This study compared the validity of pill count and self-report against plasma varenicline concentration for measuring pharmacotherapy adherence. METHODS Data were obtained from a randomized pilot study of varenicline for smoking cessation among African American smokers. Adherence was measured on Day 12 via plasma varenicline concentration, pill count, 3-day recall, and a visual analogue scale (VAS; adherence was represented on a line with two extremes "no pills" and "all pills"). RESULTS The sample consisted of 55 African American moderate to heavy smokers (average 16.8 cigarettes/day, SD = 5.6) and 63.6% were female. Significant correlations (p < .05) were found between plasma varenicline concentration and pill count (r = .56), 3-day recall (r = .46), and VAS (r = .29). Using plasma varenicline concentration of 2.0 ng/ml as the cutpoint for adherence, pill count demonstrated the largest area under the receiver operating characteristic curve (AUC = 0.85, p = .01) and had 88% sensitivity (95% CI = 75.0-95.0) and 80% specificity (95% CI = 30.0-99.0) for detecting adherence. CONCLUSIONS Of 3 commonly used adherence measures, pill count was the most valid for identifying adherence in this sample of African American smokers. Pill count has been used across other health domains and could be incorporated into treatment to identify nonadherence, which, in turn, could maximize smoking cessation pharmacotherapy use and improve abstinence rates.

Varenicline, a first-line non-nicotine medication, has not been evaluated in Black smokers, and limited attention has been paid to pharmacotherapy adherence in smoking cessation trials. This pilot study estimated quit rates for Black smokers treated with varenicline and tested a behavioral intervention to aid varenicline adherence.Seventy-two Black smokers (10 cigarettes per day; cpd) were randomly assigned to adherence support (AS; n = 36) or standard care (n = 36). All participants received 3 months of varenicline and a single counseling session focused on making a quit plan. AS participants received 5 additional counseling sessions to encourage medication use. Outcome measures included salivary cotinine, and carbon monoxide confirmed smoking abstinence, reductions in self-reported cpd, and pill counts of varenicline adherence at Months 1, 2, and 3.Sixty-one participants (84.7%) completed follow-up at Month 3. Participants were female (62.5%), 46.8 years of age, and smoked 16.3 cpd. No treatment group differences were found on the smoking or adherence outcome measures (p.05). Collapsing across treatment, varenicline adherence was adequate (86.1%), yet despite a reduction of 12.2 (6.5) cpd from baseline to Month 3 (p0.001), only 23.6% were confirmed quit at Month 3. Participants who were quit at Month 3 had higher varenicline adherence rates (95.8%) than those who continued to smoke (80.8%, p ≤ .05).Studies are needed to examine the efficacy of varenicline among Black smokers. Interventions to facilitate adherence to pharmacotherapy warrant further attention as adherence is linked to improved tobacco abstinence.

We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes.This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p0.05 was considered significant.During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP.There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.