Relationship of pain relief with catastrophizing following interventional pain procedures for low back pain.

INTRODUCTION: Catastrophizing is associated with worse pain outcomes after various procedures suggesting its utility in predicting response. However, the stability of pain catastrophizing as a static predictor has been challenged. We assess, among patients undergoing steroid injections for chronic low back pain (cLBP), whether catastrophizing changes with the clinical response to pain interventions. METHODS: This prospective study enrolled patients undergoing fluoroscopic-guided injections for cLBP. Patients filled out Brief Pain Inventory (BPI) and Pain Catastrophizing Scale (PCS) at baseline and 1-month follow-up. We assessed the change in PCS scores from pre-injection to post-injection and examined its predictors. We also examined the correlation of various domains of BPI, such as pain severity and effect on Relationships, Enjoyment, and Mood (REM), with PCS scores at baseline and follow-up. RESULTS: 128 patients were enrolled. Mean (SD) PCS and pain severity scores at baseline were 22.38 (±13.58) and 5.56 (±1.82), respectively. Follow-up PCS and pain severity scores were 19.76 (±15.25) and 4.42 (±2.38), respectively. The change in PCS pre-injection to post-injection was not significant (p=0.12). Multiple regression models revealed baseline PCS and REM domain of BPI as the most important predictors of change in PCS after injection. Pain severity, activity-related pain, age, sex, insurance status, depression, prior surgery, opioid use, or prior interventions did not predict change in PCS score. In correlation analysis, change in PCS was moderately correlated with change in pain (r=0.38), but weakly correlated with baseline pain in all pain domains. CONCLUSIONS: PCS showed non-significant improvement following steroid injections; the study was not powered for this outcome. Follow-up PCS scores were predicted by the REM domain of BPI, rather than pain severity. Larger studies are needed to evaluate a statistically significant and clinically meaningful change in catastrophizing scores following pain interventions.

A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis.

OBJECTIVE: The purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data. METHODS: We performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators. Visits meeting our history and/or examination and treatment indicators were classified as "high-quality" visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria. RESULTS: There were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a "high-quality" visit, while other regression associations were non-significant. CONCLUSION: This study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

A Prospective Cohort Study to Evaluate Needle Passes Using a Portable Ultrasound Device versus Traditional Landmark Approach for Epidural Anesthesia in a Busy Obstetric Tertiary Care Center.

Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.

"Zoom"ing to the Kitchen: A Novel Approach to Virtual Nutrition Education for Medical Trainees.

While nutritional interventions are first-line therapy for many chronic diseases, most medical trainees receive minimal nutrition education, leaving them unprepared to address nutritional issues with patients. An interactive, single-session, virtual nutrition curriculum was taught online to 80 physician assistant (PA) students. Topics included plant-based nutrition, dietary history-taking and counseling, and culinary medicine. Students were surveyed before, immediately after, and four weeks after the curriculum to assess changes to nutrition-related knowledge, attitudes, confidence, and personal dietary behaviors. Seventy-three PA students (91%) completed the pre-survey, 76 (95%) completed the post-survey, and 42 (52.5%) completed the delayed post-survey. Knowledge scores increased immediately post-intervention (48.9% to 78.9%; p < 0.001) and persisted four weeks later (78.9% to 75.8%; p = 0.54). Post-intervention, students felt more confident in dietary history-taking (55% vs. 95%; p = 0.001) and nutrition counseling (53% vs. 84%; p = 0.003) and agreed that dietary changes alone could reverse type 2 diabetes (74% vs. 97%; p = 0.027) and coronary artery disease (66% vs. 92%; p = 0.039). Curricula using virtual teaching kitchens may be a scalable approach to nutrition education for medical trainees.

Evaluating rates of chiropractic use and utilization by patient sex within the United States Veterans Health Administration: a serial cross-sectional analysis.

BACKGROUND: Within the United States Veterans Health Administration (VHA), the number of patients using healthcare services has increased over the past several decades. Females make up a small proportion of overall patients within the VHA; however, this proportion is growing rapidly. Previous studies have described rates of VHA chiropractic use; however, no prior study assessed differences in use or utilization rates between male and female veterans. The purpose of this study was to assess rates of use and utilization of chiropractic care by sex among VHA patients receiving care at VHA facilities with on-station chiropractic clinics. METHODS: A serial cross-sectional analysis of VHA national electronic health record data was conducted in Fall 2021 for fiscal year (FY) 2005-2021. The cohort population was defined as VHA facilities with on-station chiropractic clinics, and facilities were admitted to the cohort after the first FY with a minimum of 500 on-station chiropractic visits. Variables extracted included counts of unique users of any VHA on-station facility outpatient services, unique users of VHA on-station facility chiropractic services, number of chiropractic visits, and sex. To calculate use, we determined the proportion of patients of each sex who received chiropractic services to the total patients of the same sex receiving any outpatient care within each facility. To calculate utilization, we determined the number of chiropractic care visits per patient per fiscal year. A linear mixed effects model was applied to examine the difference in chiropractic care utilization by sex. RESULTS: The percentage of female VHA on-station chiropractic patients increased from 11.7 to 17.7% from FY2005-FY2021. Among VHA facilities with on-station chiropractic care, the percentage of female VHA healthcare users who used chiropractic care (mean = 2.3%) was greater than the percentage of male VHA healthcare users who used chiropractic care (mean = 1.1%). Rates of chiropractic utilization by sex among VHA facilities with on-station chiropractic clinics were slightly higher for females (median = 4.3 visits per year, mean = 4.9) compared to males (median = 4.1 visits per year, mean = 4.6). CONCLUSION: We report higher use and utilization of VHA chiropractic care by females compared with males, yet for both sexes rates were lower than in the private US healthcare system. This highlights the need for further assessment of the determinants and outcomes of VHA chiropractic care.

Expanding APHON's Pediatric Chemotherapy/Biotherapy Provider and Instructor Program to Spanish-Speaking Countries: Pilot Series Development and Evaluation.

Background: To address the need for standardized, comprehensive chemotherapy/biotherapy education in Latin American and Caribbean (LAC) countries, the Association of Pediatric Hematology/Oncology Nurses (APHON) Pediatric Chemotherapy/Biotherapy Provider and Instructor program courses were culturally adapted, translated to Spanish, and piloted. The process of course adaptation and implementation are described. A Context, Input, Process, Product model outcomes evaluation determined: (a) differences in pass rates by test version and pilot location, (b) predictors of pass rates, (c) course appropriateness for nurses' education and practice levels, and (d) strategies for course improvements. Methods: The Spanish APHON Pediatric Chemotherapy/Biotherapy Provider program was piloted four times and the Instructor program twice with nurses from Mexico, Central America, the Caribbean, South America, and Spain. Statistical analysis identified factors associated with pass rates. Results: Of the 203 students in four Spanish APHON Provider program courses, data from 108 students (three pilots) were analyzed (one unplanned pilot excluded for missing data). Significant predictors of pass rates included: pediatric oncology frontline nurses (OR = 9.86; 95% CI [2.56, 65.23]; p = .004), nurses dedicated to an inpatient or outpatient unit (non-rotating) (OR = 6.79 [1.29, 51.98]; p = .033), and graduation from a 5-year nursing program (OR = 5.92; 95% CI [1.30, 33.15]; p = .028). Discussion: The Spanish APHON Pediatric Chemotherapy/Biotherapy program was determined appropriate for nurses' education and practice levels in LAC countries. Through the APHON Spanish language instructor network, pediatric oncology nurses in LAC countries have increased access to standardized, comprehensive chemotherapy/biotherapy education.

Establishment of SEP-1 national practice guidelines does not impact fluid administration for septic shock patients.

BACKGROUND: The Centers for Medicare and Medicaid Services introduced the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) as a national quality measure in October 2015. The purpose of SEP-1 is to facilitate the efficient, effective, and timely delivery of high-quality care to patients presenting along the spectrum of sepsis severity. OBJECTIVES: The primary aim of this study was to investigate whether provider practice surrounding emergency department (ED) fluid management of suspected septic shock patients was impacted by SEP-1. METHODS: The study was a retrospective observational analysis of 470,558 patient encounters at an urban academic center over a five-year period. The sample of suspected septic shock patients was defined by the following: blood cultures collected, antibiotics administered, and vasopressors initiated. Participants were divided into two cohorts based on date of presentation (Pre-SEP-1: May 1, 2013, - August 30, 2015, and Post-SEP-1: November 1, 2015, - February 28, 2018). The primary outcome was classified as a dichotomous variable based on whether the total volume of fluids administered equaled or exceeded the calculated weight-based (≥30 cc/kg) goal. Segmented logistic regression analyses were used to assess the immediate impact of SEP-1 as well as to compare the long-term trend of fluid volume administered between Pre-SEP-1 and Post-SEP-1 cohorts. RESULTS: A total of 413 and 482 septic shock patients were included in the Pre-SEP-1 and Post-SEP-1 cohorts, respectively. There was no statistically significant change in weight-based fluid management between the cohorts. The odds of compliance with the weight-based goal decreased 22% immediately following dissemination of SEP-1, however, this was not statistically significant (log-odds = -0.25, p = 0.41). A positive trend in compliance was observed during both the Pre-SEP-1 and Post-SEP-1 periods with odds ratios increasing 0.005 and 0.018 each month, respectively, however, these findings were not statistically significant (log-odds = 0.005, p = 0.736, and log-odds = 0.018, p = 0.10, respectively). CONCLUSIONS: Overall, there were no clinically or statistically meaningful changes in fluid volume resuscitation strategies for suspected septic shock patients following SEP-1. Broad mandates may not be effective tools for promoting practice change in the ED setting. Further research investigating barrier to changes in practice patterns surrounding fluid administration and other SEP-1 bundle elements is warranted.

Longitudinal Improvements in Viral Suppression for Persons With New HIV Diagnosis Receiving Care in the Ryan White Program: A 10-Year Experience in New Haven, CT (2009-2018).

Background: The Ryan White (RW) program funds medical and other support services for low-income persons with HIV, significantly improving progress along the HIV care continuum. Although the program has shown overall improvements in achievement of viral suppression, the relative contributions of changes in clinical practice and RW service components to the optimization of the HIV care continuum, particularly for those with new HIV diagnoses, remain unknown. Methods: The target population was patients with recent HIV diagnoses who received care at RW-funded clinics in the greater New Haven area between 2009 and 2018. Client data were extracted from the RW-funded database, CAREWare, and the electronic medical record. Primary outcomes included time between HIV diagnosis and first HIV primary care (PC) visit, antiretroviral therapy (ART) initiation, and viral suppression (VS). Results: There were 386 eligible patients. Between 2009 and 2018, the median number of days from HIV diagnosis to first PC visit decreased from 58.5 to 8.5 days, and ART initiation decreased from 155 to 9 days. In 2018, 86% of participants achieved viral suppression within 1 year, compared with 2.5% in 2009. Patients who initiated single-tablet ART and integrase inhibitor-containing regimens were more likely to reach viral suppression within 1 year (P < .001). Receipt of medical case management services was also associated with achieving viral suppression (P < .001). Conclusions: Longitudinal improvements over 10 years in ART initiation and viral suppression were observed due to clinical advances and their effective implementation through the RW comprehensive care model. Further study of the essential components promoting these outcomes is needed.

Prognostic value of peripheral blood circular RNAs in patients with acute coronary syndrome.

Background: Acute coronary syndrome (ACS) is a clinical emergency. Although its prognosis has been significantly improved, some patients will have major adverse cardiovascular events (MACE) in the short term. We aimed to analyze the prognostic value of circRNAs in patients with ACS. Methods: This diagnostic accuracy study enrolled a total of 100 patients with ACS from January 2019 to January 2021. All patients were followed up for 30 days. The expression of circRNAs in peripheral blood was determined using real-time fluorescence quantification PCR (qRT-PCR). 30 patients with MACE were divided into the observation group and 70 patients without MACE were divided into the control group. The general data and the detection results of circRNAs of the two groups were compared, and the influencing factors of MACE in ACS patients were analyzed by logistic regression. Receiver operating characteristic (ROC) curves were generated, and the predictive value of peripheral blood circRNAs for MACE in patients with ACS was evaluated. Results: The age, sex, hypertension, dyslipidemia, location of coronary artery disease, left ventricular ejection fraction, and Killip grade were not significantly different between the two groups (P>0.05). Type 2 diabetes and smoking history in the observation group were also comparable between the two groups (P>0.05). Logistic regression analysis showed that type 2 diabetes mellitus [odd ratio (OR) 1.314, 95% confidence interval (CI): 1.052-1.437, P=0.002], smoking history (OR 1.227, 95% CI: 1.014-1.385, P=0.001), and the up-regulation of circRNAs in peripheral blood (OR 1.312, 95% CI: 1.028-1.452, P=0.002) were risk factors for MACE in ACS patients. The results of the ROC curve showed that peripheral blood circRNAs could be used as a predictor of MACE in patients with ACS. The best cut-off value was 96.44 ng/µL, the diagnostic sensitivity was 75.71%, the specificity was 100%, and the area under the curve (AUC) was 0.931 (95% CI: 0.884-0.977, P<0.001). Conclusions: Peripheral blood circRNAs are up-regulated about 3 fold in the peripheral blood of patients with ACS. Abnormal expression is an independent risk factor affecting MACE. Peripheral blood circRNAs can assist in clinical decision-making processes in patients with ACS.

Characteristics and productivity of the chiropractic workforce of the Veterans Health Administration.

BACKGROUND: Increasingly, integrated healthcare systems such as the United States Veterans Health Administration (VHA) are employing chiropractors. However, little is known about chiropractor employee clinical productivity which may be important for resource planning and monitoring care delivery. With its history of delivering chiropractic care and its enterprise-level assessment metrics, the VHA is an ideal setting to study a chiropractic workforce. We aim to assess characteristics of chiropractors employed by the VHA and explore associations between these characteristics and clinical productivity. METHODS: This was a cross-sectional and serial analyses of VHA administrative data. Characteristics of the chiropractor workforce were evaluated from fiscal year (FY) 2016 to FY2019. Productivity was calculated using the VHA productivity measure, the quotient of an individual's total work relative value units (wRVUs) per FY divided by the direct clinical full-time equivalent (FTE) worked. A multivariable regression model was used to analyze the association between productivity and characteristics of the chiropractor and VHA facility. RESULTS: From FY2016 to FY2019, the number of chiropractor employees increased from 102 to 167. In FY2019, the typical chiropractor employee was male, white, and 45.9 years old with 5.2 years of VHA experience. In FY2019, the VHA chiropractor workforce was 25.1% female, 79% white, and 20.4% Veteran. The productivity measure of a chiropractor was 3040 in FY2019. A higher facility complexity measure, presence of 3 chiropractor employees at a facility, and older age of the providers were the only characteristics studied that had a significant impact on productivity after adjusting for other covariates. CONCLUSION: Provider characteristics and productivity metrics of the VHA chiropractor employee workforce are presented. The productivity measure provides an initial benchmarking that may be relevant to future modeling of chiropractor personnel in VHA and other healthcare systems.

The rate of use of Veterans Affairs chiropractic care: a 5-year analysis.

BACKGROUND: The US Department of Veterans Affairs (VA) has initiated various approaches to provide chiropractic care to Veterans. Prior work has shown substantial increase in use of VA chiropractic care between fiscal years (FY) 2005-2016. However, the extent of the availability of these services to the Veteran population remains unclear. The purpose of this study was to analyze the rate of Veteran use of VA chiropractic services, both from on-site care at VA facilities and VA purchased care from community care providers. This study analyzed facility characteristics associated with chiropractic use by both care delivery mechanisms (on-site and in the community). METHODS: Cross-sectional analyses of administrative data were conducted for FY 2014-2019. Data were obtained from VA's Corporate Data Warehouse. The variables extracted included number of unique Veterans receiving VA chiropractic care on-site and in the community, total Veteran population of the VA facilities, size of the VA chiropractic workforce (measured as Full-Time Equivalent, FTE), and facility characteristics (geographic region and the facility complexity). Descriptive statistics, mixed model, and multivariant models were used to analyze data. RESULTS: Use of VA chiropractic care increased over the six-year period for both on-site and community care. National average for on-site use of the population was 1.27% in FY14 and 1.48% in FY19. Community care use was 0.29% and 1.76% for the same years. Use at individual facilities varied widely in each FY. Factors such as chiropractor FTE, geographic locations, and the complexity of the VA facility are associated with use of chiropractic services. CONCLUSION: The VA has expanded the non-pharmacologic treatments available to Veterans by providing chiropractic services, yet chiropractic use remains low compared to other US populations. As Veterans have a high prevalence of pain and musculoskeletal conditions, continued work to assess and achieve the optimal levels of chiropractic use in this population is warranted.

Application of biomaterials in periodontal tissue repair and reconstruction in the presence of inflammation under periodontitis through the foreign body response: Recent progress and perspectives.

Periodontitis would cause dental tissue damage locally. Biomaterials substantially affect the surrounding immune microenvironment through treatment-oriented local inflammatory remodeling in dental periodontitis. This remodeling process is conducive to wound healing and periodontal tissue regeneration. Recent progress in understanding the foreign body response (FBR) and immune regulation, including cell heterogeneity, and cell-cell and cell-material interactions, has provided new insights into the design criteria for biomaterials applied in treatment of periodontitis. This review discusses recent progress and perspectives in the immune regulation effects of biomaterials to augment or reconstruct soft and hard tissue in an inflammatory microenvironment of periodontitis.

Identifying highly heritable brain amyloid phenotypes through mining Alzheimer's imaging and sequencing biobank data.

Brain imaging genetics, an emerging and rapidly growing research field, studies the relationship between genetic variations and brain imaging quantitative traits (QTs) to gain new insights into the phenotypic characteristics and genetic mechanisms of the brain. Heritability is an important measurement to quantify the proportion of the observed variance in an imaging QT that is explained by genetic factors, and can often be used to prioritize brain QTs for subsequent imaging genetic association studies. Most existing studies define regional imaging QTs using predefined brain parcellation schemes such as the automated anatomical labeling (AAL) atlas. However, the power to dissect genetic underpinnings under QTs defined in such an unsupervised fashion could be negatively affected by heterogeneity within the regions in the partition. To bridge this gap, we propose a novel method to define highly heritable brain regions. Based on voxelwise heritability estimates, we extract brain regions containing spatially connected voxels with high heritability. We perform an empirical study on the amyloid imaging and whole genome sequencing data from a landmark Alzheimer's disease biobank; and demonstrate the regions defined by our method have much higher estimated heritabilities than the regions defined by the AAL atlas. Our proposed method refines the imaging endophenotype constructions in light of their genetic dissection, and yields more powerful imaging QTs for subsequent detection of genetic risk factors along with better interpretability.

The diameter factor of aligned membranes facilitates wound healing by promoting epithelialization in an immune way.

Topographical properties, such as pattern and diameter, of biomaterials play important roles in influencing cell activities and manipulating the related immune response during wound healing. We prepared aligned electrospinning membranes with different fiber diameters, including 319 ± 100 nm (A300), 588 ± 132 nm (A600), and 1048 ± 130 nm (A1000), by adjusting the distance from the tip to the collector, the injection rate, and the concentration of the solution. The A300 membranes significantly improved cell proliferation and spreading and facilitated wound healing (epithelization and vascularization) with the regeneration of immature hair follicles compared to the other membranes. Transcriptomics revealed the underlying molecular mechanism that A300 could promote immune-related processes towards a pro-healing direction, significantly promoting keratinocyte migration and skin wound healing. All the results indicated that wound healing requires the active participation of the immune process, and that A300 was a potential candidate for guided skin regeneration applications.

Application of Epigallocatechin-3-gallate (EGCG) Modified 1-Ethyl-3-(3-dimethylaminopropylcarbodiimide hydrochloride/N-hydroxy-succinimide (EDC/NHS) Cross-Linked Collagen Membrane to Promote Macrophage Adhesion.

The chemically cross-linking 1-ethyl-3-(3-dimethylaminopropylcarbodiimide hydrochloride/N-hydroxy-succinimide (EDC/NHS) collagen membrane endows such natural polymers with promising mechanical properties. Nevertheless, it is inadequate to advance the modulation of foreign body response (FBR) after implantation or guidance of tissue regeneration. In previous research, macrophages have a strong regulatory effect on regeneration, and such enhanced membranes underwent the modification with Epigallocatechin-3-gallate (EGCG) could adjust the recruitment and phenotypes of macrophages. Accordingly, we develop EGCG-EDC/NHS membranes, prepared with physical immersion, while focusing on the surface morphology through SEM, the biological activity of collagen was determined by FTIR, the activity and adhesion of cell culture in vitro, angiogenesis and monocyte/macrophage recruitment after subcutaneous implantation in vivo, are characterized. It could be concluded that it is hopeful EGCG-EDC/NHS collagen membrane can be used in implant dentistry for it not only retains the advantages of the collagen membrane itself, but also improves cell viability, adhesion, vascularization, and immunoregulation tendency.

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder.

Importance: Emergency departments (EDs) sporadically use a high-dose buprenorphine induction strategy for the treatment of opioid use disorder (OUD) in response to the increasing potency of the illicit opioid drug supply and commonly encountered delays in access to follow-up care. Objective: To examine the safety and tolerability of high-dose (>12 mg) buprenorphine induction for patients with OUD presenting to an ED. Design, Setting, and Participants: In this case series of ED encounters, data were manually abstracted from electronic health records for all ED patients with OUD treated with buprenorphine at a single, urban, safety-net hospital in Oakland, California, for the calendar year 2018. Data analysis was performed from April 2020 to March 2021. Interventions: ED physicians and advanced practice practitioners were trained on a high-dose sublingual buprenorphine induction protocol, which was then clinically implemented. Main Outcomes and Measures: Vital signs; use of supplemental oxygen; the presence of precipitated withdrawal, sedation, and respiratory depression; adverse events; length of stay; and hospitalization during and 24 hours after the ED visit were reported according to total sublingual buprenorphine dose (range, 2 to >28 mg). Results: Among a total of 391 unique patients (median [interquartile range] age, 36 [29-48] years), representing 579 encounters, 267 (68.3%) were male and 170 were (43.5%) Black. Homelessness (88 patients [22.5%]) and psychiatric disorders (161 patients [41.2%]) were common. A high dose of sublingual buprenorphine (>12 mg) was administered by 54 unique clinicians during 366 (63.2%) encounters, including 138 doses (23.8%) greater than or equal to 28 mg. No cases of respiratory depression or sedation were reported. All 5 (0.8%) cases of precipitated withdrawal had no association with dose; 4 cases occurred after doses of 8 mg of buprenorphine. Three serious adverse events unrelated to buprenorphine were identified. Nausea or vomiting was rare (2%-6% of cases). The median (interquartile range) length of stay was 2.4 (1.6-3.75) hours. Conclusions and Relevance: These findings suggest that high-dose buprenorphine induction, adopted by multiple clinicians in a single-site urban ED, was safe and well tolerated in patients with untreated OUD. Further prospective investigations conducted in multiple sites would enhance these findings.

Cognitive performance as a predictor of healthcare transition in sickle cell disease.

Neurocognitive deficits in sickle cell disease (SCD) may impair adult care engagement. We investigated the relationship between neurocognitive functioning and socio-environmental factors with healthcare transition outcomes. Adolescents aged 15-18 years who had neurocognitive testing and completed a visit with an adult provider were included. Transition outcomes included transfer interval from paediatric to adult care and retention in adult care at 12 and 24 months. Eighty adolescents (59% male, 64% HbSS/HbSß0 -thalassaemia) were included. Mean age at adult care transfer was 18·0 (±0·3) years and transfer interval was 2·0 (±2·3) months. Higher IQ (P = 0·02; PFDR  = 0·05) and higher verbal comprehension (P = 0·008; PFDR  = 0·024) were associated with <2 and <6 month transfer intervals respectively. Better performance on measures of attention was associated with higher adult care retention at 12 and 24 months (P = 0·009; PFDR  = 0·05 and P = 0·04; PFDR  = 0·12 respectively). Transfer intervals <6 months were associated with smaller households (P = 0·02; PFDR  = 0·06) and households with fewer children (P = 0·02; PFDR  = 0·06). Having a working parent was associated with less retention in adult care at 12 and 24 months (P = 0·01; P = 0·02 respectively). Lower IQ, verbal comprehension, attention difficulties and environmental factors may negatively impact transition outcomes. Neurocognitive function should be considered in transition planning for youth with SCD.

A Novel Bayesian Semi-parametric Model for Learning Heritable Imaging Traits.

Heritability analysis is an important research topic in brain imaging genetics. Its primary motivation is to identify highly heritable imaging quantitative traits (QTs) for subsequent in-depth imaging genetic analyses. Most existing studies perform heritability analyses on regional imaging QTs using predefined brain parcellation schemes such as the AAL atlas. However, the power to dissect genetic underpinnings under QTs defined in such an unsupervised fashion is largely deteriorate with inner partition noise and signal dilution. To bridge the gap, we propose a new semi-parametric Bayesian heritability estimation model to construct highly heritable imaging QTs. Our method leverages the aggregate of genetic signals to imaging QT construction by developing a new brain parcellation driven by voxel-level heritability. To ensure biological plausibility and clinical interpretability of the resulting brain heritability parcellations, hierarchical sparsity and smoothness, coupled with structural connectivity of the brain, are properly imposed on genetic effects to induce spatial contiguity of heritable imaging QTs. Using the ADNI imaging genetic data, we demonstrate the strength of our proposed method, in comparison with the standard GCTA method, in identifying highly heritable and biologically meaningful new imaging QTs.

Comparative Effects of 1/4-inch and 1/8-inch Corncob Bedding on Cage Ammonia Levels, Behavior, and Respiratory Pathology of Male C57BL/6 and 129S1/Svlm Mice.

Corncob is a common bedding material used in laboratory rodents, but little is known about differences in the effects of the 2 available sizes on rodent models and health. This study compared the effects of these 2 corncob bedding sizes on cage ammonia levels, behavior, and respiratory pathology in mice. We hypothesized that the beddings would not differ significantly in their effects on these parameters. Two strains of male mice (C57BL/6 and 129S1/Svlm) were housed in static, filter-top cages containing 1 of the 2 bedding types for the duration of the study (12 wk). Intracage ammonia was measured during 1 wk of the study on days 0, 3, 5, and 7. Behavior was evaluated by using circadian rhythm, open field, and Morris water-maze tests. Animals were euthanized with injectable euthanasia solution to collect respiratory and ocular tissues for histopathologic lesion scoring. Animals that were euthanized immediately upon arrival from the vendor served as negative controls. Bedding size did not significantly affect behavior or ammonia levels. Average intracage ammonia levels on day 7 were 525 ppm for 1/4-in. bedding and 533 ppm for 1/8-in. bedding. Regardless of the bedding size, lesions noted in both strains of mice were of similar incidence and severity, were limited to the nose, and consisted of minimal to mild suppurative rhinitis. The eyes, trachea, and lungs were not affected. In conclusion, 1/4-in. and 1/8-in. corncob beddings have comparable effects on cage ammonia levels and the behavior and respiratory pathology in male mice of the strains tested.