Inpatient opioid withdrawal: a qualitative study of the patient perspective.

Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction.

INTRODUCTION: Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature. METHODS: This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded. RESULTS: Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health. CONCLUSIONS: The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Low Dose Buprenorphine Induction With Full Agonist Overlap in Hospitalized Patients With Opioid Use Disorder: A Retrospective Cohort Study.

OBJECTIVE: To describe the outcomes of buprenorphine/naloxone low dose induction with overlap of full opioid agonists among hospitalized patients with opioid use disorder (OUD) as an alternative to standard induction strategies. METHODS: Retrospective cohort study of patients with OUD who were admitted to the hospital over a 1-year period and initiated ono buprenorphine using initial doses of 0.5 mg and gradually increased while the patient remained on full agonists. Descriptive variables included basic demographics, reason for switching to buprenorphine, baseline opioid and morphine equivalent dose. The primary outcome was a successful transition defined by the patient leaving the hospital with a buprenorphine prescription. Bivariate analysis identified factors associated with unsuccessful medication transitions. Secondary outcomes included reported withdrawal symptoms and 30 day follow up to an outpatient buprenorphine program. RESULTS: Sixty two patients underwent low dose with overlap induction during the study period. Fourteen patients were on methadone for OUD before hospital admission. Fifty one patients (82%) successfully left the hospital with a prescription for buprenorphine. Factors associated with lower likelihood of success included older age, transitioning due to discharge placement needs and presence of withdrawal symptoms during the transition. Overall, 66% (N = 23) of patients referred within the same health care system followed up within 30 days. CONCLUSIONS: Low dose inductions with overlap of full opioid agonists were largely successful in transitioning hospitalized patients from full agonist opioids to buprenorphine. However, there were several factors associated with lower likelihood of success. Future work could focus on treatment of withdrawal symptoms and system-level changes ensuring patient-centered medication decisions.

Pimping: a tradition of gendered disempowerment.

The use of pimping as a method of teaching is widespread in the clinical phase of medical education. In this paper we consider pimping's colloquial meanings and discuss how it was introduced into the language of medical education. We posit that such language reflects persistent gendered hierarchies in medicine, and we evaluate pimping's pedagogical value. Finally, we call for an end to the term and the practice, and for a renewed emphasis on pedagogy in medical education.

Student Perspectives on the "Step 1 Climate" in Preclinical Medical Education.

The United States Medical Licensing Examination Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners' preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student's Step 1 score is increasingly viewed as a key outcome of preclinical medical education.In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a "Step 1 climate." The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.

Living life without B cells: is repeated B-cell depletion a safe and effective long-term treatment plan for rheumatoid arthritis?

The continued efficacy of B-cell depletion in rheumatoid arthritis (RA) depends on repeated cycles of anti-CD20 treatment to maintain low levels of B cells. It is surprising that this significant manipulation of the humoral immune system is remarkably safe with repeated treatment and that rates of adverse effects remain stable, and may even decline, over subsequent courses. Although responses to vaccines and probably to new antigens are diminished, adaptive immunity nevertheless functions adequately despite markedly restricted B-cell numbers. In the 10 years or so since the widespread use of B-cell depletion, there is little to suggest that a long-term paucity of B cells puts patients at risk for malignancy or opportunistic infections, nor that it leads to treatment-resistant RA or complications. While time will tell whether this major alteration of the immune system has other consequences, it is remarkable that drastic reduction of B-cell numbers over the long term is tolerated so well, and that it maintains efficacy in RA therapy.

Effect of early Class II treatment on the incidence of incisor trauma.

INTRODUCTION: Many researchers have examined the prevalence of dental injuries in children and adolescents. The purpose of this study was to examine the prevalence and incidence of incisor trauma in subjects who participated in a randomized clinical trial designed to investigate early growth modifications in the treatment of Class II malocclusion. METHODS: The subjects were randomized to 3 treatment groups during the initial phase of the study: (1) headgear or biteplane, (2) bionator, and (3) observation (no treatment). All 3 groups underwent phase 2 treatment with fixed appliances. Incisor injury was scored at every data collection point with the Ellis index by a blinded examiner using dental casts, intraoral photos, and panoramic and periapical x-rays. RESULTS: Twenty-five percent of the subjects had incisor trauma at the baseline examination, and 28% experienced new or worsening maxillary incisor injury during the study. No significant differences were found with regard to sex and prevalence of injury at baseline. No differences in incidence of trauma were found between the 3 treatment groups throughout the study (P = 0.19); however, boys were more likely to experience maxillary incisor injury (odds ratio estimate, 2.37; 95% CI, 1.33, 4.21), and those with an injury at baseline were more likely to experience an additional injury (odds ratio estimate, 1.81; 95% CI, 1.03, 3.17). CONCLUSIONS: Early orthodontic treatment did not affect the incidence of incisor injury. The majority of the injuries before and during treatment were minor; therefore, the cost-benefit ratio of orthodontic treatment primarily to prevent incisor trauma is unfavorable.

Orthognathic surgery in a patient with hemophilia A: report of a case.

Hemophilia A (factor VIII deficiency) is a bleeding disorder that is inherited in a recessive fashion and is caused by a mutation on the X chromosome. Management of bleeding disorders during orthognathic surgery cases has only been reported 2 other times in the oral and maxillofacial surgery literature. This report describes a patient with a factor VIII deficiency who underwent bilateral sagittal split osteotomies, a genial advancement, and extraction of teeth and the management of this patient from a hematologic standpoint.