Factors Influencing PROMIS Scores and Patient Reported Outcomes Following Surgical Intervention of Isolated Lisfranc Injury: Minimum 2 Year Follow-up.

Lisfranc injuries are rare but significant foot injuries, as they often result from polytrauma patients, and are often misdiagnosed, which further complicate their evaluation and contribute to their propensity towards disability. It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, disability, or osteoarthritis. Our study evaluated patients who completed the patient reported outcome measurement information systems (PROMIS) along with the foot function index (FFI) following operative fixation for Lisfranc injury. Fifty-one patients between 2010 and 2020 met inclusion criteria and were selected for this study, with completion. Utilizing the electronic medical record (EMR), patient charts were reviewed to obtain basic patient demographic information and comorbidities. Operative reports were reviewed to determine which procedure was performed for definitive fixation. Primary arthrodesis was associated with a significant decrease in complication rates (p = .025) when compared to ORIF. Females, arthrodesis, and procedures using a home run (HR) screw were independent risk factors for significantly higher reports of PROMIS pain interference. Arthrodesis also was associated with lower PROMIS pain interference scores. Arthrodesis and males exhibited higher scores in all FFI categories. Our results provide evidence that patient reported outcomes following Lisfranc surgery reported via PROMIS, FFI and VAS scores are independently influenced by patient demographics, comorbidities, and surgical variables. Analysis of potential associations between these patient characteristics and PROMIS and FFI scores provides evidence for physicians to manage patient expectations prior to operative treatment of a nonpolytraumatic Lisfranc injury.

Using a Harm Reduction Approach to Treat Inpatients With Substance Use Disorders.

OBJECTIVE: This study investigated harm reduction (HR) strategies at our institution to decrease the number of patients with a substance use disorder (SUD) who left against medical advice (AMA). BACKGROUND: HR is a public health strategy used for adult substance use problems for whom abstinence is not feasible. METHODS: An HR program was established at 1 institution to enhance the care of hospitalized patients with a SUD. RESULTS: Of the 1780 unique visits for patients with a diagnosis of SUD, 311 patients (17.5%) left our hospital AMA or eloped. The average length of stay for all patients evaluated by the HR team was 6.6 days compared with 4.0 days for those who left AMA. Patients with >1 hospital stay accounted for 22% of our population but represented 34% of the patients who left AMA. CONCLUSIONS: This study reports the approaches implemented to reduce the AMA rate of patients with a SUD and to promote patient-enhanced care.

In vitro keratinocyte expansion for cell transplantation therapy is associated with differentiation and loss of basal layer derived progenitor population.

An alternative approach for traditional clinical mesh grafting in burn wound treatment is the use of expanded autologous keratinocytes in suspension or sheets that are cultured over 2-4 weeks in a remote service facility. While a wound reepithelialization has been described, the functional and aesthetic outcome is under debate. Cell isolation from split-skin donor tissue aims to preserve the valuable stem cell progenitors from the basal epidermal layer and to provide patients with a rapid wound reepithelialization and a satisfying outcome. While the presence of epidermal progenitors in the cell graft is thought to enable an improved epidermal surface post reepithelialization, we investigated a feasible clinical approach involving cultured versus noncultured epidermal cells comparing the α6int(high)/K15(high)/FSC(low)/SSC(low) and α6int(high)/K5(high)/FSC(low)/SSC(low) keratinocyte progenitor subpopulations before and after in vitro culture process. Our results show a significant increase of cell size during in vitro passaging and a decrease of progenitor markers linked to a gradual differentiation. A provision of the regenerative epidermal progenitors, isolated from the split-skin biopsy and applied directly onto the wound in an on-site setting of isolation and cell spray grafting in the operation room, could be of interest when choosing options for skin wound care with autologous cells.

Real-World Treatment Patterns and Outcomes Across Three Lines of Therapy in Patients with ALK+ NSCLC.

INTRODUCTION: Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) are standard first- and second-line treatment for advanced ALK+ non-small cell lung cancer (NSCLC). We evaluated outcomes in patients with ALK+ NSCLC receiving third-line ALK TKI versus non-ALK-directed therapy. METHODS: Flatiron Health OncoEMR data were extracted for patients with ALK+ NSCLC initiating first-line ALK TKI between January 2015 and March 2022 followed by second-line ALK TKI and third-line ALK TKI (group A) or non-TKI therapy (group B). Time-to-treatment discontinuation (TTD) and overall survival (OS) were analyzed using multivariate modelling. RESULTS: Among patients receiving third-line ALK TKI (A, n = 85) or non-TKI therapy (B, n = 43), most received first-line crizotinib (A/B: 64%/60%) and second-line alectinib (36%/30%), ceritinib (24%/19%), or lorlatinib (15%/30%). Common third-line treatments were lorlatinib/alectinib (41%/33%) in A and immunotherapy, chemotherapy, or chemotherapy + immunotherapy (30%/28%/21%) in B. Group A versus B had longer TTD of first-line treatment (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.41-0.93; p = 0.020) and second-line treatment (HR 0.50, 95% CI 0.33-0.75; p < 0.001) and longer OS from start of first-line treatment (HR 0.32, 95% CI 0.19-0.54; p < 0.001) and second-line treatment (HR 0.40, 95% CI 0.24-0.66; p < 0.001). For third-line treatment, median TTD (A/B) was 6.2/2.4 months (HR 0.61, 95% CI 0.37-1.00; p = 0.049) and OS was 17.6/6.5 months (HR 0.57, 95% CI 0.33-0.98; p = 0.042). CONCLUSIONS: Patients receiving third-line non-ALK-directed therapy had suboptimal outcomes on prior TKIs. Patients with longer duration of prior ALK TKI treatment appeared to benefit from third-line ALK TKIs.

Surgical Technologist Apprentice Program: An Innovative Approach to Improve Staffing.

Along with surgeons, anesthesia professionals, and RN circulators, surgical technologists are essential members of the perioperative team. Despite a partnership with a local community college that offered a surgical technologist degree program, Norton Healthcare in Louisville, Kentucky, continued to experience a shortage of surgical technologists. To meet demands, the clinical educators at the facility developed an in-house Surgical Technologist Apprentice Program (STAP). The STAP consists of six weeks of didactic learning and hands-on training in an OR simulation laboratory, followed by a six-month preceptorship in the OR. This program has proven invaluable, particularly as the COVID-19 pandemic increased the need for personnel who are not only skilled in the OR but also can provide essential frontline patient care when needed. Together, the STAP and the college partnership offer a career-building opportunity for those in entry-level positions who may not otherwise be able to afford to train for this specialized role.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession.

BACKGROUND: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession. METHODS: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. RESULTS: We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001). CONCLUSION: In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Leadership Immersion and Aspiring Leader Programs Designed to Improve Nurses' Well-Being and Competence: Integral Features During the COVID-19 Pandemic.

Nurse leaders play integral roles in the health care system as they focus on patient quality of care and safety at a high level and lead teams of frontline staff. Nurse leadership turnover during COVID-19 poses challenges not only for continuity of patient care but also for organizations that may fail to meet their specific goals. When a nurse leader role is not filled, gaps in care delivery occur. Our institution developed the Leadership Immersion and Aspiring Leader Programs prior to COVID-19 that provide application to theory opportunities to new nursing leaders who are prepared to fill leadership positions.

Mercury vapor volatilization from particulate generated from dental amalgam removal with a high-speed dental drill - a significant source of exposure.

BACKGROUND: The ubiquitous use of dental amalgam for over 180 years has resulted in the exposure of millions of dental workers to mercury. Dental amalgam contains approximately 50% mercury. Dental workers, including dentists, dental assistants, and dental hygienists, have been shown to have increased levels of mercury and suffer more from health issues related to mercury exposure than the general public. Mercury is known to be absorbed via inhalation or through the skin. There are many routine dental procedures that require the removal of dental amalgam by using the dental high-speed drill, which we suspected generates an occupational mercury exposure that is not sufficiently recognized. RESULTS: We showed that drilling dental amalgam generates particulate that volatilizes significant amounts of mercury vapor generally for more than an hour after removal. The levels of mercury vapor created by this procedure frequently exceed the safety thresholds of several jurisdictions and agencies. CONCLUSIONS: A significant, underrecognized source of localized exposure to mercury vapor was identified in this study. The vapor was created by microgram levels of particulate generated from dental amalgam removal with a high-speed dental drill, even when all feasible engineering controls were used to reduce mercury exposure. This exposure may explain why dental workers incur health effects when safety thresholds are not breached. The dispersion patterns for the particulate are not known, so the use of effective skin barriers and inhalation protection are required during amalgam removal to protect the dental worker from this form of occupational mercury exposure. Standard methodologies for occupational mercury exposure assessment appear to be inadequate when assessing mercury exposure during amalgam removal.

DNP-KLH Yields Changes in Leukocyte Populations and Immunoglobulin Isotype Use with Different Immunization Routes in Zebrafish.

Distinct methods are required for inducing mucosal versus systemic immunity in mammals for vaccine protection at the tissues most commonly breached by pathogens. Understanding of mucosal immunization in teleost fish is needed to combat aquaculture disease, understand emerging ecological threats, and know how vertebrate adaptive immunity evolved. Here, we quantitatively measured expression levels of IgM as well as the teleost mucosal immunoglobulin, IgZ/IgT, in zebrafish given an antigen systemically via intraperitoneal (i.p.) injection or mucosally via bath immersion. Both immunoglobulin isotypes and the B cell activating factor gene transcription was induced in fish injected with antigen as compared to saline injected or antigen immersed fish, though these failed to reach statistical significance. Here we provide additional reference hematology for this model species. Differential blood counts revealed a greater lymphocyte percentage in both i.p. and immersed fish, with increase in large lymphocyte counts and decrease in neutrophils. These humoral adaptive gene transcription and cytological data should provide a foundation for more studies connecting immunology in this dominant developmental and genetic fish model to other species where mucosal immunization is of greater commercial importance.

Optical Fiber Geometry: Accurate Measurement of Cladding Diameter.

We have developed three instruments for accurate measurement of optieal fiber cladding diameter: a contact micrometer, a scanning confocal microscope, and a white-light interference microscope. Each instrument has an estimated uncertainty (3 standard deviations) of 50 nm or less, but the confocal microscope may display a 20 nm systematic error as well. The micrometer is used to generate Standard Reference Materials that are commercially available.

Mechanisms of dendritic spine remodeling in a rat model of traumatic brain injury.

Traumatic brain injury (TBI), a leading cause of death and disability in the United States, causes potentially preventable damage in part through the dysregulation of neural calcium levels. Calcium dysregulation could affect the activity of the calcium-sensitive phosphatase calcineurin (CaN), with serious implications for neural function. The present study used both an in vitro enzymatic assay and Western blot analyses to characterize the effects of lateral fluid percussion injury on CaN activity and CaN-dependent signaling in the rat forebrain. TBI resulted in an acute alteration of CaN phosphatase activity and long-lasting alterations of its downstream effector, cofilin, an actin-depolymerizing protein. These changes occurred bilaterally in the neocortex and hippocampus, appeared to persist for hours after injury, and coincided with synapse degeneration, as suggested by a loss of the excitatory post-synaptic protein PSD-95. Interestingly, the effect of TBI on cofilin in some brain regions was blocked by a single bolus of the CaN inhibitor FK506, given 1 h post-TBI. Overall, these findings suggest a loss of synapse stability in both hemispheres of the laterally-injured brain, and offer evidence for region-specific, CaN-dependent mechanisms.

Carbon chains and the (5,5) single-walled nanotube: structure and energetics versus length.

Reliable thermochemistry is computed for infinite stretches of pure-carbon materials including acetylenic and cumulenic carbon chains, graphene sheet, and single-walled carbon nanotubes (SWCNTs) by connection to the properties of finite size molecules that grow into the infinitely long systems. Using ab initio G3 theory, the infinite cumulenic chain (:C[double bond]C[double bond]C[double bond]C:) is found to be 1.9+/-0.4 kcal/mol per carbon less stable in free energy at room temperature than the acetylenic chain (.C[triple bond]C-C[triple bond]C.) which is 24.0 kcal/mol less stable than graphite. The difference between carbon-carbon triple, double, and single bond lengths (1.257, 1.279, and 1.333 A, respectively) in infinite chains is evident but much less than with small hydrocarbon molecules. These results are used to evaluate the efficacy of similar calculations with the less rigorous PM3 semiempirical method on the (5,5) SWCNT, which is too large to be studied with high-level ab initio methods. The equilibrium electronic energy change for C(g)-->C[infinite (5,5) SWCNT] is -166.7 kcal/mol, while the corresponding free energy change at room temperature is -153.3 kcal/mol (6.7 kcal/mol less stable than graphite). A threefold alternation (6.866, 6.866, and 6.823 A) in the ring diameter of the equilibrium structure of infinitely long (5,5) SWCNT is apparent, although the stability of this structure over the constant diameter structure is small compared to the zero point energy of the nanotube. In general, different (n,m) SWCNTs have different infinite tube energetics, as well as very different energetic trends that vary significantly with length, diameter, and capping.