Implementing a tobacco-free workplace program at a substance use treatment center: a case study.

BACKGROUND: People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center. METHODS: This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice. RESULTS: Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center. CONCLUSIONS: Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Educating Substance Use Treatment Center Providers on Tobacco Use Treatments Is Associated with Increased Provision of Counseling and Medication to Patients Who Use Tobacco.

Tobacco use is the leading preventable cause of death in America and is elevated among patients with non-tobacco substance use disorders. Substance use treatment centers (SUTCs) do not commonly address their patients' tobacco use. Lack of knowledge on treating tobacco use with counseling and medication may be a barrier that underlies this inaction. A multi-component tobacco-free workplace program implemented in Texas SUTCs educated providers on treating tobacco use with evidence-based medication (or referral) and counseling. This study examined how center-level changes in knowledge from pre- to post-implementation (i.e., over time) affected center-level behavioral changes in providers' provision of tobacco use treatment over time. Providers from 15 SUTCs completed pre- and post-implementation surveys (pre N = 259; post N = 194) assessing (1) perceived barriers to treating tobacco use, specifically, a lack of knowledge on treating tobacco use with counseling or medication; (2) receipt of past-year education on treating tobacco use with counseling or medication; and (3) their intervention practices, specifically, the self-reported regular use of (a) counseling or (b) medication intervention or referral with patients who use tobacco. Generalized linear mixed models explored associations between provider-reported knowledge barriers, education receipt, and intervention practices over time. Overall, recent counseling education receipt was endorsed by 32.00% versus 70.21% of providers from pre- to post-implementation; the regular use of counseling to treat tobacco use was endorsed by 19.31% versus 28.87% from pre- to post-implementation. Recent medication education receipt was endorsed by 20.46% versus 71.88% of providers from pre- to post-implementation; the regular use of medication to treat tobacco use was endorsed by 31.66% versus 55.15% from pre- to post-implementation. All changes were statistically significant (ps < 0.05). High versus low reductions in the provider-reported barrier of "lack of knowledge on pharmacotherapy treatment" over time were a significant moderator of effects, such that SUTCs with high reductions in this barrier were more likely to report greater increases in both medication education receipt and medication treatment/referral for patients who use tobacco over time. In conclusion, a tobacco-free workplace program implementation strategy that included SUTC provider education improved knowledge and resulted in increased delivery of evidence-based treatment of tobacco use at SUTCs; however, treatment provision rates-in particular, offering tobacco cessation counseling-remained less than desirable, suggesting that barriers beyond lack of knowledge may be important to address to improve tobacco use care in SUTCs. Moderation results suggest (1) differences in the mechanisms underlying uptake of counseling education versus medication education and (2) that the relative difficulty of providing counseling versus providing medication persists regardless of knowledge gains.

Changes in Substance Use Treatment Providers' Delivery of the 5A's for Non-Cigarette Tobacco Use in the Context of a Comprehensive Tobacco-Free Workplace Program Implementation.

Tobacco use treatment is not prioritized in substance use treatment centers (SUTCs), leading to tobacco-related health inequities for patients with substance use disorders (SUDs) and necessitating efforts to enhance providers' care provision. Training providers on how to treat tobacco use increases their intervention on patients' smoking, but limited work addresses its effects on their non-cigarette tobacco use intervention provision. This study redressed this gap using data from 15 unaffiliated SUTCs in Texas (serving 82,927 patients/year) participating in a tobacco-free workplace program (TFWP) that included provider education on treating tobacco use, including non-cigarette tobacco use. SUTC providers completed surveys before (n = 259) and after (n = 194) TFWP implementation. Past-month screening/intervention provision for non-cigarette tobacco use (the 5A's; ask, advise, assess, assist, arrange) and provider factors theoretically and practically presumed to underlie change [i.e., beliefs about concurrently treating tobacco use disorder (TUD) and other SUDs, self-efficacy for tobacco use assessment (TUA) delivery, barriers to treating tobacco dependence, receipt of tobacco intervention training] were assessed. Generalized linear or linear mixed models assessed changes over time from before to after TFWP implementation; low vs. high SUTC-level changes in provider factors were examined as moderators of changes in 5A's delivery. Results indicated significant improvement in each provider factor and increases in providers' asking, assisting, and arranging for non-cigarette tobacco use over time (ps < 0.04). Relative to their counterparts, SUTCs with high changes in providers' beliefs in favor of treating patients' tobacco use had greater odds of advising, assessing, assisting, and arranging patients, and SUTCs with greater barrier reductions had greater odds of advising and assisting patients. Results suggest that TFWPs can address training deficits and alter providers' beliefs about treating non-tobacco TUD during SUD care, improve their TUA delivery self-efficacy, and reduce intervention barriers, ultimately increasing intervention provision for patients' non-cigarette tobacco use. SUTCs with the greatest room for improvement in provider beliefs and barriers to care provision seem excellent candidates for TFWP implementation aimed at increasing non-cigarette tobacco use care delivery.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers.

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Collaborative Learning: A Qualitative Study Exploring Factors Contributing to a Successful Tobacco Cessation Train-the-Trainer Program as a Community of Practice.

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4-6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee "champions'" train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020-May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Economic Evaluation of a Crisis Residential Program.

This study assessed the cost savings to the local health care system from using a 16-bed crisis residential facility (the Inn) in Austin, Texas, instead of hospitalization, for individuals with acute psychiatric illness (N=1,364) during FY2017-FY2019. Health service utilization data were obtained from the provider and Central Texas's regional health information exchange. Unit cost data were obtained from the provider, Austin State Hospital, the Healthcare Cost and Utilization Project, and the Medical Expenditure Panel Survey. Results indicated that the Inn saved the health care system up to $2.8 million annually. Future work can use these findings to improve the efficiency and effectiveness of the mental health care system.

An epidemic and a pandemic collide: Assessing the feasibility of tobacco treatment among vulnerable groups at COVID-19 protective lodging.

INTRODUCTION: Individuals experiencing homelessness have elevated smoking rates in addition to chronic and acute physical and mental health conditions, which may increase chances for complications associated with COVID-19 recovery. Unfortunately, there is underuse of tobacco cessation services in many agencies (e.g., substance use treatment centers, mental health treatment centers) providing care to these individuals. The purpose of the current study was to evaluate the feasibility of providing tobacco cessation treatment alongside local COVID-19 emergency response efforts. METHOD: Taking Texas Tobacco Free (TTTF) partnered with relevant emergency response teams at 5 isolation centers (repurposed hotels) in Austin, Texas, to address tobacco use among presumed or confirmed COVID-19 positive individuals who had nowhere else to seek care and shelter. TTTF trained staff on tobacco cessation treatment; specifically, the 5A's and use of nicotine replacement therapy. RESULTS: Over 5 months in 2020; 170 of 379 (44.9%) isolation center residents were reached and assessed for cigarette or vape use. Smoking/vaping prevalence was 70.6%, and 41.7% of tobacco users accepted cessation treatment. DISCUSSION: Results suggest the feasibility and potential acceptability of providing tobacco treatment services in similar care settings during local emergency response efforts, including but potentially not limited to the COVID-19 pandemic. Further, this initiates a call to action for health care providers to deliver tobacco use cessation services for typically hard-to-reach groups (e.g., individuals/families experiencing homelessness) who may have increased contact with service agencies and health providers during times of crisis. Limitations and suggestions for future implementation are also provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Organizational Factors Moderating Changes in Tobacco Use Dependence Care Delivery Following a Comprehensive Tobacco-Free Workplace Intervention in Non-Profit Substance Use Treatment Centers.

Although tobacco use is the leading preventable cause of death and is elevated among patients with substance use disorders, many substance use treatment centers (SUTCs) do not offer tobacco use interventions (i.e., screening and treatment). This study examined a key outcome of the implementation of a tobacco-free workplace program that provided education and specialized training to employees; namely, changes in clinician provision of the five As (Asking about tobacco use; Advising to quit; Assessing willingness to quit; Assisting with quitting; Arranging follow-up) from before to after the larger program implementation. The five As are a brief tobacco screening and treatment protocol that was taught as part of the program and that formed the basis for further intervention (e.g., provision of nicotine replacement therapies, Motivational Interviewing to enhance desire and willingness to make a quit attempt). Moreover, we also examined organizational moderators that may have impacted changes in the delivery of the five As over time among clinicians from 15 participating SUTCs. The number of the centers' total and unique annual patient visits; full-time employees; and organizational readiness for implementing change were assessed as potential moderators of change in clinicians' behaviors over time. Clinicians completed pre- and post-program implementation surveys assessing their provision of the five As. Results demonstrated significant increases in Asking (p = 0.0036), Advising (p = 0.0176), Assisting (p < 0.0001), and Arranging (p < 0.0001). SUTCs with higher Change Efficacy (p = 0.025) and lower Resource Availability (p = 0.019) had greater increases in Asking. SUTCs with lower Resource Availability had greater increases in Assessing (p = 0.010). These results help guide tobacco control program implementation to increase the provision of tobacco use interventions (i.e., the five As) to SUTC patients and elucidate Change Efficacy and Resource Availability as organizational factors promoting this clinician behavior change.

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers.

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p's < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.

Addressing Smoking Cessation among Women in Substance Use Treatment: A Qualitative Approach to Guiding Tailored Interventions.

Intersecting socially marginalized identities and unique biopsychosocial factors place women with substance use disorders (SUDs) experiencing myriad disadvantages at higher risk for smoking and stigmatization. Here, based on our work with women receiving care for SUDs in four participating treatment/women-serving centers (N = 6 individual clinics), we: (1) describe the functions of smoking for women with SUDs; and (2) explore participants' experiences of a comprehensive tobacco-free workplace (TFW) program, Taking Texas Tobacco-Free (TTTF), that was implemented during their SUD treatment. Ultimately, information gleaned was intended to inform the development of women-tailored tobacco interventions. Data collection occurred pre- and post-TTTF implementation and entailed conducting client (7) and clinician (5) focus groups. Using thematic analysis, we identified four main themes: "the social context of smoking," "challenges to finding support and better coping methods," "addressing underlying conditions: building inner and outer supportive environments," and "sustaining support: TFW program experiences." Women reported that: smoking served as a "coping mechanism" for stress and facilitated socialization; stigmatization hindered quitting; non-stigmatizing counseling cessation support provided alternative coping strategies; and, with clinicians, the cessation opportunities TTTF presented are valuable. Clinicians reported organizational support, or lack thereof, and tobacco-related misconceptions as the main facilitator/barriers to treating tobacco addiction. Effective tobacco cessation interventions for women with SUDs should be informed by, and tailored to, their gendered experiences, needs, and recommendations. Participants recommended replacing smoking with healthy stress alleviating strategies; the importance of adopting non-judgmental, supportive, cessation interventions; and the support of TFW programs and nicotine replacement therapy to aid in quitting.

Implementation and Outcomes of a Comprehensive Tobacco Free Workplace Program in Opioid Treatment Centers.

Tobacco use is exceedingly high among individuals receiving care for opioid addiction, but not commonly addressed by clinicians in treatment settings. Taking Texas Tobacco Free (TTTF) is a comprehensive tobacco-free workplace (TFW) program that builds treatment centers' capacity to address tobacco use with evidence-based tobacco cessation policies and practices. Here, we examine the process and outcomes of TTTF's implementation within 7 opioid addiction centers. Program goals were structured according to the RE-AIM framework. Pre- and post-implementation data were collected from client facing and non-client facing employees to assess changes in education, training receipt, knowledge, and intervention behaviors, relative to program goals. Centers reported tobacco screenings conducted and nicotine replacement therapy (NRT) delivered through 6 months post-implementation. Overall, 64.56% of employees participated in TTTF-delivered tobacco education, with a 54.9% gain in tobacco control and treatment knowledge (p < 0.0001), and significant increases in exposure to education about tobacco use and harms among individuals with opioid use disorder (p = 0.0401). There were significant gains in clinicians' receipt of training in 9/9 tobacco education areas (ps ≤ 0.0118). From pre- to post-implementation, there were mean increases in the use of the 5A's (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with statistically significant gains seen in NRT provision/referral (p < 0.0001). Several program goals were achieved or exceeded; however, 100% center participation in specialized clinical trainings was among notable exceptions. One program withdrew due to competing pandemic concerns; all others implemented comprehensive TFW policies. Overall, TTTF may have improved participating opioid treatment centers' capacity to address tobacco use, although study limitations, including lower post-implementation evaluation response rates, suggest that results require replication in other opioid addiction treatment settings.

Tobacco-free Workplace Program at a Substance Use Treatment Center.

Objectives: About 65%-87% of substance use disorder patients smoke cigarettes, compared to 14% of the general adult population. Few substance use treatment centers (SUTCs) have comprehensive tobacco-free workplace (TFW) policies or offer tobacco interventions. Taking Texas Tobacco Free (TTTF) implements an evidence-based TFW program in SUTCs, including at the Billy T. Cattan Recovery Outreach Center (BTC). We present a mixed methods case study of BTC's TTTF implementation, success factors, and challenges. Methods: TTTF provided policy development assistance, training, treatment resources, and technical assistance over ∼9 months. Implementation was tailored using mixed methods. Quantitative data included surveys to stakeholders (Nmax = 7), a pre- and post-training questionnaire assessing knowledge gain, and reported quantities of tobacco use assessments (TUAs) administered and nicotine replacement therapy (NRT) provided. Qualitative data included stakeholder focus groups and interviews (18 participants). Results: All employees reported TFW policy compliance. Employees exhibited a 20% knowledge gain. Clinicians increased self-report of NRT provision and tobacco cessation counseling. During implementation, BTC administered TUAs to 171 patients and dispensed NRT to 70 of 110 tobacco-using patients. Conclusion: Qualitative findings contextualized quantitative outcomes. TTTF implementation changed clinician attitudes, knowledge, and practices regarding tobacco treatment, facilitating patient quit attempts.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed.

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.

Protein-Losing Enteropathy as the Initial Presentation of Gastrointestinal Kaposi's Sarcoma in Previously Undiagnosed HIV Disease.

Occult Kaposi's sarcoma (KS) presenting as a protein-losing gastroenteropathy is a rare occurrence. We report the case of a 23-year-old male presenting with leg bilateral swelling and epigastric discomfort. A workup revealed human immunodeficiency virus seropositivity, hypoalbuminemia, and small bowel wall thickening on computed tomography scan. Initially there were no mucosal or cutaneous lesions visible. An upper endoscopy demonstrated subepithelial lesions with a reddish appearance involving the palate, cardia, duodenum, and jejunum, consistent with KS. Gastrointestinal involvement is the most common extracutaneous site of KS and is found in about half of the acquired immune deficiency syndrome (AIDS)-related cases. However, only one out of 5 patients are symptomatic in the absence of skin lesions. Antiretroviral therapy along with anthracycline chemotherapy must be promptly initiated to improve chances of survival.

Retrospective Analysis of Septic Arthritis Caused by Intra-Articular Viscosupplementation and Steroid Injections in a Single Outpatient Center.

BACKGROUND: Septic arthritis is defined by the presence of pathogen(s) in a joint by direct inoculation or hematogenous spread. Most common organisms include Staphylococcus aureus and Escherichia coli. Clinical presentation is fever, warmth and night pain, with most common joints involved being the knee and hip. Iatrogenic septic arthritis is an uncommon complication of intra-articular injection for osteoarthritis yet its complications can be devastating. We aim to highlight ten cases of iatrogenic septic arthritis in retrospective study reviewing symptoms, signs, laboratory data, causing organisms and reasons leading to those infections. METHODS: Retrospective analysis of charts of ten patients who were admitted to Jersey Shore University Medical Center with diagnosis of iatrogenic septic arthritis. RESULTS: Average age of patients is 69.9 years. Most common comorbidities seen in our patient were hypertension and diabetes mellitus. The most common intra-articular agents that were injected were cortisone and Synvisc. The mean incubation period was 11.9 days. Most common presenting symptoms were joint pain and swelling. The most common organism isolated in cultures was Streptococcus mitis. A total of 100% of patients underwent surgical intervention for septic arthritis. One case was complicated by sepsis. CONCLUSIONS: Iatrogenic septic arthritis is not common; however its complications can be catastrophic to patients. Improper sterile techniques and untrained physicians are the main risks factors for this complication. Physicians should take proper sterile measures to avoid complications of intra-articular injections.

A Case of Anterior Spinal Artery Syndrome Caused by Streptococcus mitis Endocarditis.

BACKGROUND: Infectious endocarditis (IE) typically occurs in the setting of intravenous drug use, prosthetic heart valves, or rheumatic heart disease. However, there are a few reports of IE occurring in the setting of immunosuppression secondary to cancer and/or chemotherapy. Here, we present a case of a cancer patient who developed anterior spinal artery (ASA) syndrome secondary to a septic embolus from IE. CASE PRESENTATION: A 78-year-old male with a history of gastroesophageal cancer treated with chemotherapy and radiation presented to the hospital after a fall at home. He reported experiencing dyspnea and orthopnea for two weeks prior to presentation. In the ED, his vital signs were stable, and his examination was significant for a flaccid paralysis of the right lower extremity. Diagnosis of septic emboli secondary to IE was made after the echocardiogram showed the presence of vegetations on the aortic valve, blood cultures were positive for Streptococcus mitis, and thoracic spine MRI was indicative of an infarction at T10. DISCUSSION: This case highlights the presence of IE in the setting of cancer and chemotherapy. Although cancer is a rare cause of IE, clinicians must maintain a high index of suspicion in order to minimize the sequelae of IE.

Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education.

PURPOSE: Robust global health demands access to safe, affordable, timely surgical care for all. The long-term success of global surgery requires medical students to understand and engage with this emerging field. The authors characterized medical students' perceptions of surgical care relative to other fields within global health. METHOD: An optional, anonymous survey was given to all Johns Hopkins medical students from February to March 2016 to assess perceptions of surgical care and its role in global health. RESULTS: Of 480 students, 365 (76%) completed the survey, with 150 (41%) reporting global health interests. One-third (34%) of responding students felt that surgical care is one of two fields with the greatest potential global health impact in the future, second to infectious disease (49%). A minority (28%) correctly identified that trauma results in more deaths worldwide than obstetric complications or HIV/AIDS, tuberculosis, and malaria combined. Relative to other examined fields, students perceived surgical care as the least preventive and cost-effective, and few students (3%) considered adequate surgical care the best indicator of a robust health care system. Students believed that practicing in a surgical field was least amenable to pursuing a global health career, citing several barriers. CONCLUSIONS: Medical students have several perceptions of global surgery that contradict current evidence and literature, which may have implications for their career choices. Opportunities to improve students' global health knowledge and awareness of global surgery career paths include updating curricula, fostering meaningful international academic opportunities, and creating centers of global surgery and global health consortia.