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Purpose. To summarize essential information for the hospital pharmacist to support the safe and effective use of insulin for the treatment of inpatient hyperglycemia. Summary. Ensuring optimal insulin utilization in the hospital setting requires collaboration of a multidisciplinary team, including physicians (and endocrinologists specifically), nurses, pharmacists, dieticians, diabetes educators, laboratory staff, quality management staff, and others. The role of pharmacists in this multidisciplinary team is to assist in the standardization of insulin therapy via selection of appropriate insulin treatment protocols, participate in formulary management of insulin products, and contribute to the development of order sets and policies and procedures to minimize the risk of medication errors and misadventures. In addition, pharmacists can provide guidelines or treatment recommendations in special situations, such as those involving patients receiving enteral or parenteral nutrition or high-dose corticosteroids and the transition from i.v. to subcutaneous insulin therapy. Education of patients and providers is another key role for pharmacists. Nurses are important allies in the effort to ensure safe insulin use, as they are at the bedside of patients administering and adjusting insulin therapy. Recommendations are provided for the safe and effective use of insulin for the treatment of inpatient hyperglycemia. Conclusion. Pharmacists are an integral part of the multidisciplinary team ensuring the safe and effective implementation of inpatient hyperglycemic control and insulin usage. [ABSTRACT FROM AUTHOR]

The resuscitation of severe burn remains a controversial area within the burn care profession. There is ongoing debate as to what percentage burn is associated with a sufficient quality of life to support initial resuscitation efforts. We conducted a survey of delegates at the 39th Annual Meeting of the British Burns Association (2005), regarding attitudes towards resuscitation following major burns. Respondents were asked the maximum percentage total body surface area (TBSA) burn beyond which they would not wish to be resuscitated. They were also asked what maximum TBSA they perceived to be commensurate with an acceptable quality of life (QOL). One hundred and forty three of 300 delegates responded to the questionnaire. Thirty three percent of respondents would not wish to be resuscitated with 50-75% TBSA burns or greater. A further 35% would not wish to have life-sustaining intervention with 75-95% TBSA burns or greater. The remaining 32% indicated that they would not want resuscitation with TBSA burns>95%. Regardless of TBSA affected, 16% would not wish resuscitation if they had full thickness facial burns, a further 10% did not want resuscitation if both their hands and faces were affected. Our survey demonstrates the diversity of personal preference amongst burn care professionals. This would suggest that a unifying philosophy regarding the resuscitation of extensive burns will remain elusive. [ABSTRACT FROM AUTHOR]

Many patients with obstructive sleep apnoea (OSA) remain undiagnosed and thus untreated, and in part this relates to delay in diagnosis. Novel diagnostic strategies may improve access to diagnosis. In a multicentre, randomised study, we evaluated time to treatment decision in patients referred for suspected OSA, comparing a mandibular movement (MM) monitor to respiratory polygraphy, the most commonly used OSA detection method in the UK. Adults with high pre-test probability OSA were recruited from both northern Scotland and London. 40 participants (70 % male, mean±SD age 46.8 ± 12.9 years, BMI 36.9 ± 7.5 kg/m 2 , ESS 14.9 ± 4.1) wore a MM monitor and respiratory polygraphy simultaneously overnight and were randomised (1:1) to receive their treatment decision based on results from either device. Compared to respiratory polygraphy, MM monitor reduced time to treatment decision by 6 days (median(IQR): 13.5 (7.0-21.5) vs. 19.5 (13.7-35.5) days, P = 0.017) and saved an estimated 29 min of staff time per patient., Competing Interests: Declaraton of competing interest MJM discloses being a co-applicant on a European Institute of Innovation & Technology grant, developing e-health and integrated care. MIP discloses being a paid consultant for Philips Respironics. JLK discloses speaking fees from Sunrise SA., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Meniere's disease (MD) is defined by episodic vertigo, unilateral sensorineural hearing loss and fluctuating aural symptoms. Due to the variable clinical presentation, objective tests of MD may have significant diagnostic utility. Head kinematics derived from a head-mounted display (HMD) have demonstrated to be sensitive to vestibular dysfunction. The purpose of this pilot study was to investigate whether head sway can differentiate between patients with MD, vestibular hypofunction (VH) and healthy controls., Materials/methods: 80 adults (30 healthy controls, 32 with VH, and 18 with MD) were recruited from a tertiary vestibular clinic. All underwent a postural control assessment using the HTC Vive Pro Eye HMD that recorded head sway in the anterior-posterior (AP), medio-lateral (ML), pitch, yaw and roll direction. Participants were tested with 2 levels of visual load: a static versus oscillating star display. Each scene lasted 60 s and was repeated twice. Sway in each direction was quantified using root mean square velocity (VRMS) for the first 20 s and full 60 s of each scene., Results: Static visual: participants with VH showed significantly larger head VRMS than controls in the AP (60 s and 20 s) and pitch (20 s) directions. Dynamic visual: participants with VH showed significantly larger head VRMS than controls all directions for both the 60 and 20 s analysis. Participants with MD did not differ significantly from the control or the VH group., Conclusion: While limited in numbers, Patients with MD had a high variability in head sway in all directions, and their average head sway was between controls and those with VH. A larger sample as well as patients with worse symptoms at time of testing could elucidate whether head sway via HMD could become a viable test in this population. A similar finding between 20- and 60-s scene and the full portability of the system with an in-clinic testing setup could help these future endeavors. Head sway derived from HMD is sensitive to VH and can be clinically useful as an outcome measure to evaluate sensory integration for postural control., Competing Interests: MC is an unpaid consultant for Cochlear Americas and reported unpaid participation in research on cochlear implants and other implantable devices manufactured by Cochlear Ltd. and MED-El outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Kelly, Cosetti and Lubetzky.)

Background: A post hoc analysis of the MERGE trial was conducted, to investigate whether sex differences are evident at the mildest end of the disease spectrum, for symptoms associated with obstructive sleep apnoea (OSA) and the response to continuous positive airway pressure (CPAP) treatment., Methods: MERGE participants with mild OSA (apnoea-hypopnoea index 5-15 events·h -1 ; American Academy of Sleep Medicine 2012 criteria) were randomised to either CPAP plus standard care (sleep hygiene counselling) or standard care alone for 3 months. Quality of life (QoL) was measured by questionnaires completed before and after the 3 months. This post hoc analysis of participants of the MERGE trial compared the symptom presentation, and response to CPAP, between the sexes., Results: 233 patients were included; 71 (30%) were female. Females were more symptomatic at baseline in all QoL questionnaires. Specifically, females had lower 36-item Short-Form Health Survey (SF-36) Vitality scores (mean±sd 39.1±10.1 versus 44.8±10.3) and higher Epworth Sleepiness Scale (ESS) scores (mean±sd 11.0±4.2 versus 9.5±4.4). Both sexes experienced snoring, but more females reported fatigue and more males reported witnessed apnoeas. All symptoms improved with CPAP for both sexes; however, females had larger improvements in SF-36 Vitality scores, which was the primary outcome of the MERGE trial (mean change 9.4 (95% CI 6.8-12.0) versus 6.0 (95% CI 4.3-7.7); p=0.034), and ESS (mean change -4.1 (95% CI -5.1- -3.0) versus -2.5 (95% CI -3.1- -1.8); p=0.015), after adjustment for baseline scores and CPAP usage., Conclusions: Sex differences are apparent in patients with mild OSA. Females experience worse QoL symptoms than males at presentation to the sleep clinic; however, these improve significantly with CPAP treatment., Competing Interests: Conflict of interest: A.J. Wimms is an employee of ResMed. Conflict of interest: J.L. Kelly has received personal fees from Sunrise, outside the scope of this work. Conflict of interest: C.D. Turnbull has received personal fees from Stowood, outside the scope of this work. Conflict of interest: A. McMillan has no conflict of interest. Conflict of interest: S.E. Craig has no conflict of interest. Conflict of interest: J.F. O'Reilly has no conflict of interest. Conflict of interest: A.H. Nickol has no conflict of interest. Conflict of interest: M.D. Decker confirms that they have no conflicts of interest (presence or absence) that might raise the question of bias in the work reported or the conclusions, implications or opinions stated in this manuscript, with the exception that they are working as an independent paid statistical consultant for ResMed Corporation. Conflict of interest: L.A. Willes confirms that they have no conflicts of interest (presence or absence) that might raise the question of bias in the work reported or the conclusions, implications or opinions stated in this manuscript, with the exception that they are working as an independent paid statistical consultant for ResMed Corporation. Conflict of interest: P.M.A. Calverley has no conflict of interest. Conflict of interest: A.V. Benjafield is an employee of ResMed. Conflict of interest: J.R. Stradling has received personal fees from ResMed UK, and a grant and personal fees from Bayer during the course of, but unrelated to, this study. Conflict of interest: M.J. Morrell has no conflict of interest., (Copyright ©The authors 2024.)

Introduction: Vibrotactile positional therapy (PT) devices are a new treatment modality for positional obstructive sleep apnoea (POSA). This review aimed to determine the effect of vibrotactile PT on the Apnoea Hypopnoea Index (AHI) and the percentage of time spent in the supine position (%Tsupine) in patients with POSA, compared with baseline. Secondary aims were to investigate the effect on daytime sleepiness, quality of life and sleep quality., Methods: A systematic review and meta-analysis was performed of randomised controlled trials (RCTs) and cohort studies that investigated the effect of vibrotactile PT in POSA patients. Searches were performed via MEDLINE, CENTRAL and Embase up to 29 October 2022., Results: 1119 studies were identified, 18 studies met the inclusion criteria (10 RCTs, 8 cohort studies). The use of vibrotactile PT significantly reduced the AHI at follow-up compared with baseline (mean difference (95% CI) -9.19 events/hour (-11.68 to -6.70); p<0.00001). The mean %Tsupine was also significantly reduced (mean difference (95% CI) -32.79% (-38.75% to -26.83%); p<0.00001). The percentage changes in the AHI and %Tsupine were 43% and 70%, respectively. Secondary outcomes were daytime sleepiness, quality of life and sleep indices. These showed minimal change, although follow-up was short., Conclusion: Vibrotactile PT devices are effective in treating POSA; reducing both AHI and %Tsupine. The effect on sleep quality, daytime sleepiness and disease-specific quality of life was minimal. However, there were limited data and follow-up was often brief, meaning that further research is needed to determine the effect of vibrotactile PT on patient-centred outcomes., Prospero Registration Number: CRD42020188617., Competing Interests: Competing interests: JLK, MJM and CDT disclose research funding from the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0817-20049) for the POSA Trial (NCT04153240)., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Eastern oysters, Crassostrea virginica , are commercially important coastal species that provide many ecosystem services for coastal communities. Unfortunately, 85% of oyster reefs have been lost globally, prompting investments in restoration efforts to rebuild populations. Managers often consider several well-studied environmental and water quality parameters when making restoration site decisions. However, recent research suggests that submarine groundwater discharge (SGD) may play a role in driving the distribution of oysters in some estuaries. Specifically, SGD may result in localized areas of low dissolved oxygen and low pH that could inhibit oyster recruitment and survival. However, SGD may interact with other potential oyster stressors, including creek geomorphology. On point bars, sediment accumulation could alter growth rates of oysters and physiology, and it is possible that the two factors, SGD and creek geomorphology, could interact to impact oyster growth. We conducted a field experiment to examine the effects of SGD and creek geomorphology on oyster growth rates in a marsh-lined tidal creek in Georgia, USA. High and low SGD sites were paired within point bars and cut banks. Oysters were deployed in cages for 72 days and growth rates were determined. We found a significant interaction between SGD and creek geomorphology on oyster growth rates. Oysters grew at significantly faster rates at locations on accretionary point bars regardless of SGD flux, whereas, on erosional cut banks, high SGD flux significantly reduced oyster growth rate relative to low SGD flux. It appears that SGD may negatively influence oyster growth at specific creek locations, likely due to the presence of other stressors. Therefore, it is important to consider potential interacting and confounding stressors when managing oyster populations. As SGD is still a relatively understudied potential stressor for oysters, it is critical to continue to examine how groundwater might influence oysters in other locations and in combination with other stressors. Regardless, this study provides further evidence that SGD should be considered in future management efforts., Competing Interests: The authors declare that they have no competing interests., (© 2023 Carroll et al.)

Objective: This study aimed to evaluate the effectiveness of tai chi on balance in patients with improved but persistent dizziness and imbalance following completion of traditional vestibular rehabilitation therapy., Method: Patients who completed vestibular rehabilitation therapy with persistent imbalance were prospectively enrolled in a tai chi programme comprising eight weekly classes. Balance was assessed before the first and after the eighth session using the Dynamic Gait Index, Activities-Specific Balance Confidence scale and Dizziness Handicap Inventory., Results: A total of 37 participants (34 females, 3 males) completed the programme with balance testing. Mean age was 76.8 years (range, 56-91 years). Mean Dynamic Gait Index significantly increased after completion of tai chi ( p < 0.00001). Mean Activities-Specific Balance Confidence scale score increased from 63.6 to 67.9 per cent ( p = 0.046). A subset ( n = 18) of patients completed a Dizziness Handicap Inventory without significant post-therapeutic change ( p = 0.62). Most (36 of 37; 97.3 per cent) patients demonstrated post-therapy improvement on one or more assessments., Conclusion: Tai chi is a viable adjunct to improve balance in patients who complete a vestibular rehabilitation therapy programme.

Objectives: The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal., Background: Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed., Methods: We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply., Results: 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess., Conclusions: In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The coronavirus disease 2019 pandemic has accelerated the adoption of virtual care strategies for the management of patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS)., Research Question: What is the effectiveness of virtual consultations compared to in-person consultations for the management of continuous positive airway pressure (CPAP) therapy in adult patients with OSAHS?, Methods: A systematic review and meta-analysis (PROSPERO; CRD42022297532) based on six electronic databases plus manually selected journals was conducted in January 2022. Two researchers independently selected, quality appraised and extracted data. The co-primary outcomes were patient-reported sleepiness, assessed by the Epworth Sleepiness Scale (ESS), and reported cost-effectiveness., Results: 12 studies (n=1823 adults) were included in the review. Seven studies (n=1089) were included in the meta-analysis which showed no difference in the magnitude of improvement in patient-reported sleepiness scores between virtual and in-person consultations (mean difference -0.39, 95% CI -1.38-0.60; p=0.4), although ESS scores improved in both groups. Virtual care strategies modestly increased CPAP therapy adherence and were found to be less costly than in-person care strategies in the three Spanish trials that reported cost-effectiveness., Conclusion: The findings of this review suggest that virtual care delivered by telephone or video consultations is as effective as in-person consultations for improving subjective sleepiness in patients with OSAHS treated with CPAP. This clinical management strategy may also improve CPAP adherence without increasing the costs, supporting its potential as a follow-up management strategy, where patients prefer this approach., Competing Interests: Conflict of interest: The authors have nothing to disclose., (Copyright ©The authors 2022.)

This pilot study aimed to identify postural strategies in response to sensory perturbations (visual, auditory, somatosensory) in adults with and without sensory loss. We tested people with unilateral peripheral vestibular hypofunction (N = 12, mean age 62 range 23-78), or with Unilateral Sensorineural Hearing Loss (USNHL, N = 9, 48, 22-82), or healthy controls (N = 21, 52, 28-80). Postural sway and head kinematics parameters (Directional Path in the anterior-posterior and medio-lateral directions (sway & head); pitch, yaw and roll (head) were analyzed in response to 2 levels of auditory (none, rhythmic sounds via headphones), visual (static, dynamic) and somatosensory cues (floor, foam) within a simulated, virtual 3-wall display of stars. We found no differences with the rhythmic auditory cues. The effect of foam was magnified in the vestibular group compared with controls for anterior-posterior and medio-lateral postural sway, and all head direction except for medio-lateral. The vestibular group had significantly larger anterior-posterior and medio-lateral postural sway and head movement on the static scene compared with controls. Differences in pitch, yaw and roll emerged between vestibular and controls only with sensory perturbations. The USNHL group did not increase their postural sway and head movement with the increased visual load as much as controls did, particularly when standing on the foam. They did not increase their medio-lateral sway with the foam as much as controls did. These findings suggest that individuals with USNHL employ a compensatory strategy of conscious control of balance, the functional implications of which need to be tested in future research., Competing Interests: The authors have declared that no competing interests exist.

Biodegradable temporising matrix (BTM NovoSorb; PolyNovo, Melbourne, Australia) is a novel synthetic polyurethane dermal substitute. Licensed in Europe in 2020, it was developed primarily for reconstruction of infected wounds. We present a case of a healthy man in his 60s with necrotising fasciitis of his left thigh. His medical history was significant for recurrent left thigh liposarcoma that was treated years earlier with surgical excision and adjuvant radiotherapy. The affected area was within the previously irradiated tissue, debrided down to fascia and dressed with a vacuum-assisted closure to help regenerate the wound bed. Reconstruction options were limited by having a circumferential thigh defect that was infected. Following the use of NovoSorb BTM, the area was dressed with Acticoat Flex 7 antimicrobial barrier dressing for 5 weeks. Patient mobilisation was permitted. The material integrated very well and formed a soft, pliable healthy dermal layer that was autografted with split thickness skin grafts. This resulted in durable cover of the thigh with good aesthetic contour and minimal contracture., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Merkel cell carcinoma (MCC) is an aggressive malignancy of presumed neuroendocrine origin. Most case series of MCC are limited by low case numbers and are not specific to head and neck tumours. The purpose of this study was to provide a focused review of head and neck MCC diagnosis and management in a single Irish institution., Methods: Patient's demographics, tumour characteristics, pathological diagnosis, surgical treatment, adjuvant treatment, subsequent management and clinical course were collected. Estimates of progression-free MCC survival rates were calculated by the Kaplan-Meier statistical model. A Pearson product-moment correlation coefficient examined the association between surgical margins and disease-free follow-up., Results: In total, 11 patients were treated for head and neck MCC with a mean age of 79.6 years (range = 69-91 years). The mean average follow-up duration of patients was 18.3 months. Of the cohort, 18% ( n =2) had a sentinel node biopsy (SLNB). A selective neck dissection was subsequently performed in 18% ( n =2). In total, 72% ( n =8) of patients received adjuvant radiotherapy. Median disease-specific survival was 15 months for the SLNB group and 17 months for the non-SLNB group, not statistically significant ( p =0.23). There was no significant association between surgical margins and disease-free follow ( p =0.65)., Conclusions: Our case series adds to a limited body of evidence of head and neck MCC. Surgery remains the treatment priority in localized disease, with an increasing role of SLNB for accurate prognostication and staging. Early management of stage I disease results in moderate long-term disease-free survivability., (© 2022 The Authors.)

Background: The capacity to diagnose obstructive sleep apnoea (OSA) must be expanded to meet an estimated disease burden of nearly one billion people worldwide. Validated alternatives to the gold standard polysomnography (PSG) will improve access to testing and treatment. This study aimed to evaluate the diagnosis of OSA, using measurements of mandibular movement (MM) combined with automated machine learning analysis, compared to in-home PSG., Methods: 40 suspected OSA patients underwent single overnight in-home sleep testing with PSG (Nox A1, ResMed, Australia) and simultaneous MM monitoring (Sunrise, Sunrise SA, Belgium). PSG recordings were manually analysed by two expert sleep centres (Grenoble and London); MM analysis was automated. The Obstructive Respiratory Disturbance Index calculated from the MM monitoring (MM-ORDI) was compared to the PSG (PSG-ORDI) using intraclass correlation coefficient and Bland-Altman analysis. Receiver operating characteristic curves (ROC) were constructed to optimise the diagnostic performance of the MM monitor at different PSG-ORDI thresholds (5, 15, and 30 events/hour)., Results: 31 patients were included in the analysis (58% men; mean (SD) age: 48 (15) years; BMI: 30.4 (7.6) kg/m 2 ). Good agreement was observed between MM-ORDI and PSG-ORDI (median bias 0.00; 95% CI -23.25 to + 9.73 events/hour). However, for 15 patients with no or mild OSA, MM monitoring overestimated disease severity (PSG-ORDI < 5: MM-ORDI mean overestimation + 5.58 (95% CI + 2.03 to + 7.46) events/hour; PSG-ORDI > 5-15: MM-ORDI overestimation + 3.70 (95% CI -0.53 to + 18.32) events/hour). In 16 patients with moderate-severe OSA ( n = 9 with PSG-ORDI 15-30 events/h and n = 7 with a PSG-ORD > 30 events/h), there was an underestimation (PSG-ORDI > 15: MM-ORDI underestimation -8.70 (95% CI -28.46 to + 4.01) events/hour). ROC optimal cut-off values for PSG-ORDI thresholds of 5, 15, 30 events/hour were: 9.53, 12.65 and 24.81 events/hour, respectively. These cut-off values yielded a sensitivity of 88, 100 and 79%, and a specificity of 100, 75, 96%. The positive predictive values were: 100, 80, 95% and the negative predictive values 89, 100, 82%, respectively., Conclusion: The diagnosis of OSA, using MM with machine learning analysis, is comparable to manually scored in-home PSG. Therefore, this novel monitor could be a convenient diagnostic tool that can easily be used in the patients' own home., Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT04262557., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kelly, Ben Messaoud, Joyeux-Faure, Terrail, Tamisier, Martinot, Le-Dong, Morrell and Pépin.)

Background: The optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS)., Methods: We searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month's duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO 2 , PaO 2 and NIV adherence (PROSPERO CRD42019132398)., Findings: Of 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO 2 (0.61 mm Hg (95% CI -2.15 to 3.38); p=0.68), PaO 2 (-0.00 mm Hg (95% CI -4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI -0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome., Interpretation: Oronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks., Competing Interests: Competing interests: ML has no conflict of interest to declare related to the present work. He received speaker fees from Air Liquide Medical System, and Sefam, and non-financial support from Nomics outside the context of the submitted work. He received a salary from Air Liquide Medical System as a medical trainer. A Léotard has no conflict of interest to declare related to the present work. JC Borel is salaried by AGIR à dom, a home-care provider. JL Pépin and his department has received research support and personal fees from Philips Respironics, Sefam, Fisher and Paykel, and ResMed. JLP is supported by the French National Research Agency in the framework of the "Investissements d’avenir” program (ANR-15-IDEX-02) and the “e-health and integrated care and trajectories medicine and MIAI artificial intelligence” Chairs of excellence from the Grenoble Alpes University Foundation. This work has been partially supported by MIAI @ Grenoble Alpes (ANR-19-P3IA-0003). M Dreher has received speaking and advisor fees from companies in the field of mechanical ventilation; in addition, his study group received an open research grant from ResMed. JH Storre reports grants and personal fees for lectures from Heinen und Löwenstein and VitalAire, grants, personal fees for lectures and non-financial support for meeting attendance from Vivisol GmbH, grants from Weinmann Deutschland, personal fees for consultancy/advisory board work from Breas Medical AB regarding the submitted work; personal fees for consultancy and lectures, and non-financial support for meeting attendance from Boehringer Ingelheim Pharma, personal fees for consultancy and lectures from SenTec AG, Keller Medical GmbH, Linde Deutschland and Santis GmbH, outside the submitted work. M Patout reports personal fees from Resmed, Philips Respironics, grants and non-financial support from Fisher & Paykel, non-financial support and personal fees from Asten, research grants from B& D Electromedical and Fisher & Paykel, personal fees and non-financial support from Chiesi outside the submitted work. GC Funk received speaker fees from Draeger and Getinge. PJ Wijkstra reports grants and personal fees from Philips, grants and personal fees from RESMED, grants from Vital Air, grants from VIVISOL, grants from Goedegebuure, personal fees from Synapse, personal fees from Bresotec, outside the submitted work., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Reef-building eastern oysters, Crassostrea virginica, provide many ecosystem services, including production of valuable commercial products, formation of complex habitats, improved water quality and shoreline protection. Despite this, oyster populations have experienced dramatic declines throughout their range, spawning massive investment in management and restoration. Restoration efforts typically consider several well-studied metrics that normally influence oyster success; however, one potential factor that has not received much prior attention is submarine groundwater discharge (SGD). We conducted a series of field surveys and field experiments to explore the relationship between SGD and oysters in a marsh-lined tidal creek in Georgia, USA. SGD was mapped across multiple time points using a natural radon tracer (radon-222), and fluxes were paired with discrete measurements of oyster density, condition, size, recruitment and growth at multiple locations along the creek. Variation in oyster metrics was best explained by a combination of SGD, pH, and DO, which displayed a high degree of multicollinearity. We found an overall negative, nonlinear relationship between oyster density and groundwater flux. Interestingly, juvenile and adult condition and growth were not negatively impacted by groundwater. Rather, our results suggest that the likely mechanism for the density-flux relationship was interruption of the larval recruitment, which was also negatively related to flux. We hypothesize that larval interruption is due to the low dissolved oxygen and pH conditions of the groundwater at high flux sites. Overall, the interaction between SGD and oysters appears complex, and may be affected by other variables. This study provides evidence of a potential negative effect of a previously understudied natural phenomena on oyster demographics, and we suggest that SGD be considered in future management efforts., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Virtual reality allows for testing of multisensory integration for balance using portable Head Mounted Displays (HMDs). HMDs provide head kinematics data while showing a moving scene when participants are not. Are HMDs useful to investigate postural control? We used an HMD to investigate postural sway and head kinematics changes in response to auditory and visual perturbations and whether this response varies by context. We tested 25 healthy adults, and a small sample of people with diverse monaural hearing ( n = 7), or unilateral vestibular dysfunction ( n = 7). Participants stood naturally on a stable force-plate and looked at 2 environments via the Oculus Rift (abstract "stars;" busy "street") with 3 visual and auditory levels (static, "low," "high"). We quantified medio-lateral (ML) and anterior-posterior (AP) postural sway path from the center-of-pressure data and ML, AP, pitch, yaw and roll head path from the headset. We found no difference between the different combinations of "low" and "high" visuals and sounds. We then combined all perturbations data into "dynamic" and compared it to the static level. The increase in path between "static" and "dynamic" was significantly larger in the city environment for: Postural sway ML, Head ML, AP, pitch and roll. The majority of the vestibular group moved more than controls, particularly around the head, when the scenes, especially the city, were dynamic. Several patients with monaural hearing performed similar to controls whereas others, particularly older participants, performed worse. In conclusion, responses to sensory perturbations are magnified around the head. Significant differences in performance between environments support the importance of context in sensory integration. Future studies should further investigate the sensitivity of head kinematics to diagnose vestibular disorders and the implications of aging with hearing loss to postural control. Balance assessment and rehabilitation should be conducted in different environmental contexts., Competing Interests: MC reported unpaid participation in research on cochlear implants and other implantable devices manufactured by Advanced Bionics, Cochlear Americas, MED-El, and Oticon Medical outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lubetzky, Kelly, Hujsak, Liu, Harel and Cosetti.)

Background: To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%., Study Design: We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients' opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire., Results: Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients., Conclusions: This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

This report describes a novel technique of steroid infiltration of the wrist to treat symptomatic carpal tunnel syndrome. Our approach potentially reduces direct trauma to the median nerve when compared with current conventional techniques. The use of a cannula allows infiltration directly into the carpal tunnel and advancement of the blunt tip minimises the risk of sharp trauma to the median nerve and adjacent tendons. This avoids the unpleasant, shooting pain frequently experienced by patients using traditional needle infiltration. We anticipate this would be of particular benefit in reducing pain associated with the procedure., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized., Methods: A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees., Results: During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year., Conclusions: Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Cell-assembled tissue engineering strategies hold great potential in regenerative medicine, as three-dimensional tissue-like modules can be produced, even from a patient's own cells. However, the development of such implantable devices requires prolonged in vitro culture time, which is associated with cell phenotypic drift. Considering that the cells in vivo are subjected to numerous stimuli, multifactorial approaches are continuously gaining pace towards controlling cell fate during in vitro expansion. Herein, we assessed the synergistic effect of simultaneous and serial growth factor supplementation (insulin growth factor-1, platelet-derived growth factor ββ, growth differentiation factor 5 and transforming growth factor β 3) to macromolecular crowding (carrageenan) in human tenocyte function; collagen synthesis and deposition; and gene expression. TGF β 3 supplementation (without/with carrageenan) induced the highest (among all groups) DNA content. In all cases, tenocyte proliferation was significantly increased as a function of time in culture, whilst metabolic activity was not affected. Carrageenan supplementation induced significantly higher collagen deposition than groups without carrageenan (without/with any growth factor). Of all the growth factors used, TGF β 3 induced the highest collagen deposition when used together with carrageenan in both simultaneous and serial fashion. At day 13, gene expression analysis revealed that TGF β 3 in serial supplementation to carrageenan upregulated the most and downregulated the least collagen- and tendon- related genes and upregulated the least and downregulated the most osteo-, chondro-, fibrosis- and adipose- related trans-differentiation genes. Collectively, these data clearly advocate the beneficial effects of multifactorial approaches (in this case, growth factor and macromolecular crowding supplementation) in the development of functional cell-assembled tissue surrogates., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s). Published by Elsevier Ltd.)

Introduction: The advent of wide-awake local anaesthesia has led to a reduced need for main theatre for trauma and elective plastic procedures. This results in significant cost-benefits for the institution. This study aims to show how a dedicated 7 days/ week plastic surgery procedural (PSP) unit, performing both elective and trauma surgeries, can lead to significant cost-benefits for the institution., Methods: Retrospective review of all cases performed in the PSP unit between 1 September and 31 August 2018. We utilised hospital directory admissions data and the hospital's intranet operating theatre system to calculate hospital days saved. Cost analysis was performed using Saolta financial data., Results: A total of 3058 operations were performed. Of these operations, 2388 cases were elective and 670 were trauma cases. The average waiting time for trauma cases for main operating theatre was 1.4 days, saving a total of 487 hospital days. The total savings associated with hospital bed days were €347,861. The estimated resource savings from performing a procedure in PSP compared with main theatre with regional anaesthesia were €529.00 and €391.00 without regional anaesthesia. The cost saved due to resources was therefore €337,226. The total cost-benefit associated with performing surgeries in PSP including hospital days and resources saved was calculated as €685,087., Conclusion: This study shows the benefit of performing elective and trauma operations in minor procedure units such as PSP. PSP results in a more efficient service, reducing waiting times for surgery, shorter hospital stay, reduced operating cost and an overall significant cost saving., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Inpatient data for COVID-19 (SARS-CoV-2) afflicted inpatients remain sparse. Data are needed to create accurate projections for resource consumption as the pandemic continues. Published reports of inpatient data have come from China, Italy, Singapore, and both the East and West coasts of the United States., Objective: The objective is to present our inpatient experience with COVID-19. Design, Setting, and Participants . This is a retrospective study of 681 patients with laboratory-confirmed COVID-19 from six hospitals in the Denver metropolitan area admitted between February 18 and April 30, 2020. Clinical outcomes of patients discharged or expired by April 30, 2020, were analyzed. Main Outcomes . We compiled patient demographics, length of stay, number of patients transferred to or admitted to the ICU, ICU length of stay, mechanical ventilation requirements, and mortality rates., Results: Of the 890 patients with laboratory-confirmed COVID-19, 681 had discharged and were included in this analysis. We observed 100% survival of the 0-18 age group ( n  = 2), 97% survival of the 19-30 age group, 95% survival of the 31-64 age group, 79% survival of the 65-84 age group, and 75% survival of the 85 and older age group. Our total inpatient mortality was 13% (91 patients), rising to 29% (59 patients) for those requiring ICU care., Conclusions: Compared to similar reports from other metropolitan areas, our analysis of discharged or expired COVID-19 patients from six major hospitals in the Denver metropolitan area revealed a lower mortality. This includes the subset of patients admitted to the ICU regardless of the need for intubation. A lower ICU length of stay was also observed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Paula J. Watts et al.)

Oxygen is of critical importance to tissue viability and there is increasing demand for its reliable real-time clinical monitoring in order to prevent, diagnose, and treat several pathological disorders, including hypoxia, stroke and reperfusion injury. Herein we report the development and characterisation of a prototype clinical O2 sensor, and its validation in vivo, including proof-of-concept monitoring in patients undergoing surgery for carpal tunnel release. An integrated platinum-based microelectrochemical device was custom designed and controlled using a miniaturised telemetry-operated single channel clinical potentiostat. The in vitro performance of different sensor configurations is presented, with the best sensor design (S2) displaying appropriate linearity (R2 = 0.994) and sensitivity (0.569 ± 0.022 nA μM-1). Pre-clinical validation of S2 was performed in the hind limb muscle of anaesthetised rats; tourniquet application resulted in a significant rapid decrease in signal (90 ± 27%, [ΔO2] ca. 140 ± 18 μM), with a return to baseline within a period of ca. 3 min following tourniquet release. Similar trends were observed in the clinical study; an immediate decrease in signal (39 ± 3%, [ΔO2] ca. 30 ± 20 μM), with basal levels re-established within 2 min of tourniquet release. These results confirm that continuous real-time monitoring of dynamic changes in tissue O2 can serve as an indicator of reperfusion status in patients undergoing carpal tunnel surgery, and suggests the potential usefulness of the developed microelectrochemical sensor for other medical conditions where clinical monitoring of O2 and perfusion is important.

Background: The evidence base for the treatment of mild obstructive sleep apnoea is limited and definitions of disease severity vary. The MERGE trial investigated the clinical effectiveness of continuous positive airway pressure in patients with mild obstructive sleep apnoea., Methods: MERGE, a multicentre, parallel, randomised controlled trial enrolled patients (≥18 years to ≤80 years) with mild obstructive sleep apnoea (apnoea-hypopnoea index [AHI] ≥5 to ≤15 events per h using either AASM 2007 or AASM 2012 scoring criteria) from 11 UK sleep centres. Participants were assigned (1:1) to either 3 months of continuous positive airway pressure plus standard care (sleep counselling), or standard care alone, by computer-generated randomisation; neither participants nor researchers were blinded. The primary outcome was a change in the score on the Short Form-36 questionnaire vitality scale in the intention-to-treat population of patients with mild obstructive sleep apnoea diagnosed using the American Academy of Sleep Medicine 2012 scoring criteria. The study is registered with ClinicalTrials.gov, NCT02699463., Findings: Between Nov 28, 2016 and Feb 12, 2019, 301 patients were recruited and randomised. 233 had mild obstructive sleep apnoea using AASM 2012 criteria and were included in the intention-to-treat analysis: 115 were allocated to receive continuous positive airway pressure and 118 to receive standard care. 209 (90%) of these participants completed the trial. The vitality score significantly increased with a treatment effect of a mean of 10·0 points (95% CI 7·2-12·8; p<0·0001) after 3 months of continuous positive airway pressure, compared with standard care alone (9·2 points [6·8 to 11·6] vs -0·8 points [-3·2 to 1·5]). Using the ANCOVA last-observation-carried-forward analysis, a more conservative estimate, the vitality score also significantly increased with a treatment effect of a mean of 7·5 points (95% CI 5·3 to 9·6; p<0·0001) after 3 months of continuous positive airway pressure, compared with standard care alone (7·5 points [6·0 to 9·0] vs 0·0 points [-1·5 to 1·5]). Three serious adverse events occurred (one allocated to the continuous positive airway pressure group) and all were unrelated to the intervention., Interpretation: 3 months of treatment with continuous positive airway pressure improved the quality of life in patients with mild obstructive sleep apnoea. These results highlight the need for health-care professionals and providers to consider treatment for patients with mild obstructive sleep apnoea., Funding: ResMed Ltd., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Cellular therapies play an important role in tendon tissue engineering, with tenocytes being the most prominent and potent cell population available. However, for the development of a rich extracellular matrix tenocyte-assembled tendon equivalent, prolonged in vitro culture is required, which is associated with phenotypic drift. Recapitulation of tendon tissue microenvironment in vitro with cues that enhance and accelerate extracellular matrix synthesis and deposition, whilst maintaining tenocyte phenotype, may lead to functional cell therapies. Herein, we assessed the synergistic effect of low oxygen tension (enhances extracellular matrix synthesis) and macromolecular crowding (enhances extracellular matrix deposition) in human tenocyte culture. Protein analysis demonstrated that human tenocytes at 2% oxygen tension and with 50 μg ml -1 carrageenan (macromolecular crowder used) significantly increased synthesis and deposition of collagen types I, III, V and VI. Gene analysis at day 7 illustrated that human tenocytes at 2% oxygen tension and with 50 μg ml -1 carrageenan significantly increased the expression of prolyl 4-hydroxylase subunit alpha 1, procollagen-lysine 2- oxoglutarate 5-dioxygenase 2, scleraxis, tenomodulin and elastin, whilst chondrogenic (e.g. runt-related transcription factor 2, cartilage oligomeric matrix protein, aggrecan) and osteogenic (e.g. secreted phosphoprotein 1, bone gamma-carboxyglutamate protein) trans-differentiation markers were significantly down-regulated or remained unchanged. Collectively, our data clearly illustrates the beneficial synergistic effect of low oxygen tension and macromolecular crowding in the accelerated development of tissue equivalents.

The practice of medicine is occasionally volatile and increasingly litigious. Within the specialities, plastic surgery has a high risk, with negative outcomes seen as dissatisfaction, as compared to actual physical harm. To date, most research has focused on potential triggers for litigation, such as poor communication and perceived behavioural deficiencies among physicians. Few studies have addressed patient characteristics or socioeconomic factors. The 'Influence of Socio-Economic Factors on Attitudes Towards Surgery' questionnaire was designed to reflect these goals. It was distributed for a 12-month period to patients in an Emergency Department waiting room. Three hundred twelve completed questionnaires were submitted for analysis. Within the study population, we identified certain socioeconomic trends among those with a low threshold to pursue litigation. Patients with a low threshold to sue were more likely to be male, aged 25-55 years, currently unemployed, without dependents and divorced. However, these parameters did not reach statistical significance. Although these characteristics are interesting, they cannot reliably identify or predict those with a low threshold for litigation. For now, the clinical focus should remain on careful adherence to best practice in an effort to reduce the risk of potential litigation., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Importance: Opioid overdose is the leading cause of injury-related death in the United States. Several studies have shown that surgeons overprescribe opioids, and guidelines for appropriate opioid prescribing are available. Concern about patient-reported satisfaction scores may be a barrier to surgeons adopting guideline-directed prescribing., Objective: To determine whether decreased opioid prescribing is associated with a decrease in patient-reported satisfaction with their surgeon., Design, Setting, and Participants: Retrospective analysis of clinician satisfaction scores at Dartmouth-Hitchcock Medical Center obtained in 2 periods: 1 before (period A) and 1 after (period B) an educational intervention that resulted in decreased opioid prescribing. The analysis included 11 surgeons who performed 5 common outpatient general surgical operations on 996 patients. Data were analyzed between March and August 2018., Main Outcomes and Measures: Patient-reported overall satisfaction rating of the surgeon (scale, 0-10). This was collected by a nonstudy-related, routine general institutional survey of approximately 40% of all outpatient encounters., Results: Of the total number of patients, 67% were women (667 of 996), and the mean patient age was 58 years. Comparing period A with B, the proportion of patients prescribed opioids decreased from 90.2% (n = 367 of 407) to 72.8% (n = 429 of 589) (P < .001). The mean number of opioid pills per prescription decreased from 28.3 to 13.3 (P < .001) and significantly decreased for each of the 11 surgeons. One hundred five of 996 patients (10.5%) undergoing index operations responded to the survey. There was no difference in the mean clinician satisfaction ratings from period A vs B (9.70 vs 9.65; P = .69). During the study periods, 640 total surveys were collected referencing these surgeons (including outpatient encounters associated with operations other than the 5 index cases). There was no difference in the mean satisfaction ratings from period A vs period B (9.55 vs 9.59; P = .62). When individual clinicians were analyzed, none had a significant difference in overall satisfaction rating from period A vs period B., Conclusions and Relevance: Despite a marked decrease in the proportion of patients receiving opioids and in the number of pills prescribed, there was no significant change in clinician satisfaction ratings.

Background: Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases., Methods: This study aimed to determine the distance (cm) and surface area (cm 2 ) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens., Results: The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm 2 compared to 85.36 cm 2 after division of both the origin and insertion., Conclusion: Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects., (© 2019 Royal Australasian College of Surgeons.)

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66. 1 This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services., (Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Platysma bands are characteristic of an aging neck. Resection and plication of the platysma muscle is the basis of treatment. However, unfavorable surgical outcomes and improved understanding of platysma band etiology have shifted treatment towards nonsurgical rejuvenation., Objectives: The aim of this paper was to assess the efficacy, injection techniques, and complications associated with botulinum toxin injection for the treatment of platysma bands., Methods: A systematic literature search was performed to identify articles reporting botulinum toxin injections for platysma bands in neck rejuvenation. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and the Cochrane Library-between January 1985 and December 2017., Results: Three studies met the inclusion criteria, with a total of 78 patients undergoing botulinum toxin injection for platysma bands. Incobotulinumtoxin A was used in 62.3% (n = 45/78) of patients, with 38.4% (n = 30/78) receiving abobotulinumtoxin A. Efficacy was assessed using the Merz platysma score scale. A mean score improvement of 2.0 points, with a response rate of 93.7%, was observed after 14 ± 2 days. At 3 months, the mean score improvement was 1.2 points with a response rate of 86%. Patient-reported metrics demonstrated an improvement in 91% (n = 71/78) of subjects. The three studies used a standard injection technique, with a maximum 20 IU of incobotulinumtoxin A and 5 U abobotulinumtoxin A administered per band. Complications were reported in 15.4% (n = 12/78) of patients, with none requiring further intervention., Conclusions: Botulinum toxin is a highly effective treatment for isolated platysma bands. A safe injection technique is described and recommended for clinical practice.

We describe a useful strategy to accurately identify the correct 'atypical' nevus for excision in patients with multiple nevi. We believe this is an effective strategy and eliminates risk of any incorrect procedures being performed, and have used this technique on over 50 patients to date. As the patient stores the images on their own phone, there is no breach of data protection. We find patients prefer this method as opposed to giving others permission to store their sensitive information.

Importance: Most states have adopted the routine use of a prescription drug monitoring program (PDMP) to curb overprescribing of opioids. The American College of Surgeons promotes the use of these programs as a "guiding principle to curb the opioid epidemic." However, there is a paucity of data on the effects of the use of these programs for surgical patient populations., Objective: To determine the association of the mandatory use of a PDMP with the opioid prescribing practices for patients undergoing general surgery., Design, Setting, and Participants: A prospective observational cohort study was conducted at an academic hospital in New Hampshire among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017., Exposures: New state legislation mandated the use of a PDMP and opioid risk-assessment tool for all patients receiving an outpatient opioid prescription in New Hampshire beginning January 1, 2017. The electronic medical prescribing system was modified to facilitate and support compliance with the new requirements., Main Outcomes and Measures: Change in opioid prescribing practices after January 1, 2017, and time to complete PDMP requirements., Results: Among the 1057 patients (569 women [53.8%] and 488 men [46.2%]; mean [SD] age, 56.8 [15.4] years), the percentage of patients prescribed opioids after surgery did not decrease significantly (429 of 536 [80.0%] before the new requirements vs 401 of 521 [77.0%] after the requirements; P = .29). The mean number of opioid pills prescribed decreased from 30.8 to 24.0 (22.1%) in the 6 months prior to the mandatory PDMP requirement; the rate of decrease was actually less (from 22.8 to 21.9 pills [3.9%]) in the 6 months after the legislation. These new requirements did not identify any high-risk patients who subsequently were not prescribed opioids. The query and opioid abuse risk calculator together took a median time of 7 minutes (range, 2-17 minutes) to complete., Conclusions and Relevance: A mandatory PDMP query requirement was not significantly associated with the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures. In no cases was a high-risk patient identified, leading to avoidance of an opioid prescription. A PDMP can be a useful adjunct in certain settings, but this study found that it did not have the intended effect in a population undergoing elective surgical procedures. Legislative efforts to mandate PDMP use should be targeted to populations in which benefit can be demonstrated.

Background: Deficits in sensory integration and fear of falling in complex environments contribute to decreased participation of adults with vestibular disorders. With recent advances in virtual reality technology, head-mounted displays are affordable and allow manipulation of the environment to test postural responses to visual changes., Objectives: To develop an assessment of static and dynamic balance with the Oculus Rift and (1) to assess test-retest reliability of each scene in adults with and without vestibular hypofunction; (2) to describe changes in directional path and sample entropy in response to changes in visuals and surface and compare between groups; and (3) to evaluate the relation between balance performance and self-reported disability and balance confidence., Design: Test-retest, blocked-randomized experimental design., Setting: Research laboratory., Participants: Twenty-five adults with vestibular hypofunction and 16 age- and sex-matched adults., Methods: Participants stood on the floor or stability trainers while wearing the Oculus Rift. For 3 moving "stars" scenes, they stood naturally. For a "park" scene, they were asked to avoid a virtual ball. The protocol was repeated 1-4 weeks later., Outcome: Anteroposterior and mediolateral center-of-pressure directional path and sample entropy were derived from a force plate., Results: We observed good to excellent reliability in the 2 groups, with most intraclass correlations above 0.8 and only 2 at approximately 0.4. The vestibular group had higher directional path for the stars scenes and lower directional path for the park scene compared with controls, with large variability in the 2 groups. Sample entropy decreased with more challenging environments. In the vestibular group, less balance confidence strongly correlated with more sway for the stars scenes and less sway for the park scene., Conclusion: Virtual reality paradigms can shed light on the control mechanism of static and dynamic postural control. Clinical utility and implementation of our portable Oculus Rift assessment should be further studied., Level of Evidence: II., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Overuse injuries are common in physically active populations. Lower limb overuse injuries can occur anywhere in the lower-extremity and include injuries such as medial tibial stress syndrome, plantar fasciitis, and anterior knee pain. One reason that overuse injuries have received attention is because they have both short- and long-term consequences on health and burden the lives of physically active people. Over the years, a variety of approaches have been proposed for prevention of lower limb overuse injury that addresses various intrinsic or extrinsic risk factors. One extrinsic risk factor is footwear and the use of orthotic insoles to prevent injury. To date, there is no consensus as to whether these supports prevented lower limb overuse injuries. A critical appraisal of recent studies examining the injury prevention capabilities of orthotic insoles was completed. The long-term objective of this research is to help identify effective strategies for preventing injuries in physically active people.

Objective: To evaluate a longitudinal experiential training model for advanced pharmacy practice experiences (APPEs)., Innovation: A six-month longitudinal pilot program named the Focused Institutional Longitudinal Experience (FILE) program was developed at two academic medical centers to maximize active participation of the student and minimize the time spent orienting and onboarding students to each APPE experience. A unique component of the FILE program is the longitudinal service project, which involved a medication use evaluation, including a review of published literature and drug policy recommendations to medical center quality committees., Analysis: Student ratings regarding the quality and value of the FILE student experience was compared to the traditional APPE model. Nine quality measures were compared (e.g. amount of opportunity for direct patient care experience, learning, integration into healthcare team, and accountability for patient outcomes) between students from the FILE program to peers completing similar APPEs outside the FILE program. FILE students and APPE preceptors also completed surveys regarding the value of several program aspects., Key Findings: There was no difference between FILE and non-FILE student self-rated measures of APPE quality, and thus the decision to participate in a longitudinal APPE program should be based on the personal preference of the student. Students in the FILE program agreed or strongly agreed (mean score 4.3) that they felt prepared for post-graduate training at the completion of the program. The potential value that students in a longitudinal program might bring to the site is reinforced by the general agreement by preceptors in the end of year survey that FILE students take less of their time to orient to their service and the trend toward perception that FILE students are more likely to independently participate in patient care activities., Next Steps: To address feedback on preceptor-mentor role and the desire for more interaction with pharmacy residents, students are now paired with a pharmacy resident, and the student and resident work together on the service project with a clinical pharmacist as an advisor. Updated standards of practice clearly delineate the roles and responsibilities of students, residents, and the clinical pharmacist preceptor. Annual surveys of FILE students and preceptors provide necessary feedback to continuously improve the quality of the program., (© University of Minnesota Libraries Publishing.)