Re-Purposing FDA-Approved Drugs for Opioid Use Disorder.

OBJECTIVE: To investigate FDA-approved drugs prescribed for unrelated diseases or conditions that promote remission in subjects diagnosed with opioid use disorder (OUD). METHODS: This was a retrospective observational study utilizing the TriNetX electronic medical record data. Subjects between 18 and 65 years old were included in this study. First, a drug screen was employed to identify medications used for chronic illness that are associated with OUD remission. Based on Fisher's exact test for significance, 28 of 101 medications were selected for further analysis. Positive (buprenorphine/methadone) and negative controls (benazepril) were included in the analysis. Medications were analyzed in the absence and presence of buprenorphine or methadone, two medications used to treat OUD, to identify the likelihood of OUD remission up to one year following the index event. RESULTS: We identify 8 medications (prazosin, propranolol, lithium carbonate, olanzapine, quetiapine, bupropion, citalopram, and escitalopram) that may be useful for increasing remission in OUD in the absence of buprenorphine or methadone. Additionally, our results identify psychiatric medications that when taken alongside buprenorphine and methadone improve remission rates. CONCLUSION: These results provide medication options that may be useful in treating OUD as well as integrated therapies to treat comorbid mental illness.

Formulation, pilot-scale preparation, physicochemical characterization and digestibility of a lentil protein-based model infant formula powder.

BACKGROUND: Infant formula is a human milk substitute for consumption during the first months of life. The protein component of such products is generally of dairy origin. Alternative sources of protein, such as those of plant origin, are of interest due to dairy allergies, intolerances, and ethical and environmental considerations. Lentils have high levels of protein (20-30%) with a good amino acid profile and functional properties. In this study, a model lentil protein-based formula (LF), in powder format, was produced and compared to two commercial plant-based infant formulae (i.e., soy; SF and rice; RF) in terms of physicochemical properties and digestibility. RESULTS: The macronutrient composition was similar between all the samples; however, RF and SF had larger volume-weighted mean particle diameters (D[4,3] of 121-134 µm) than LF (31.9 µm), which was confirmed using scanning electron and confocal laser microscopy. The larger particle sizes of the commercial powders were attributed to their agglomeration during the drying process. Regarding functional properties, the LF showed higher D[4,3] values (17.8 µm) after 18 h reconstitution in water, compared with the SF and RF (5.82 and 4.55 µm, respectively), which could be partially attributed to hydrophobic protein-protein interactions. Regarding viscosity at 95 °C and physical stability, LF was more stable than RF. The digestibility analysis showed LF to have similar values (P < 0.05) to the standard SF. CONCLUSION: These results demonstrated that, from the nutritional and physicochemical perspectives, lentil proteins represent a good alternative to other sources of plant proteins (e.g., soy and rice) in infant nutritional products. © 2021 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

An appraisal of lymph node ratio in colon and rectal cancer: not one size fits all.

BACKGROUND: Lymph node ratio (LNR) is increasingly accepted as a useful prognostic indicator in colorectal cancer. However, variations in methodology, statistical stringency and cohort composition has led to inconsistency in respect of the optimally prognostic LNR. OBJECTIVE: The aim was to apply a robust regression-based analysis to generate and appraise LNRs optimally prognostic for colon and rectal cancer, both separately and in combination. METHODS: LNR was established for all patients undergoing either a colonic (n = 379) or rectal (n = 160) cancer resection with curative intent. The optimal LNR associated with disease-free and overall survival were established using a classification and regression tree technique. This process was repeated separately for patients who underwent either colonic or rectal resection and for the combined cohort. Survival associated with differing LNR was estimated using the Kaplan-Meier method and compared using a log-rank test. Relationships between LNR, disease-free survival (DFS) and overall survival (OS) were further characterised using Cox regression analysis. All statistical analyses were conducted in the R programming environment, with statistical significance was taken at a level of p < 0.05. RESULTS: Optimal LNRs differed between each cohort, when either overall or disease-free survival was considered. LNRs generated from combined cohorts also differed from those generated by individual cohorts. In relation to DFS, LNR values were obtained and included 0.18 for the colon cancer cohort and 0.19 for the rectal and combined colorectal cancer cohorts. In relation to OS, multiple LNR values were obtained for colon and combined cohorts; however, an optimal LNR was not evident in the rectal cancer cohort. Survival patterns according to LNR closely resembled those associated with standard nodal staging. CONCLUSION: Application of a data-driven approach based on recursive partitioning generates differing lymph node ratios for colon, rectal and combined colorectal cohorts. In each cohort, LNR was similarly prognostic to standard nodal staging in respect to overall and disease-free survival. Overall survival was associated with a multiplicity of LNR values, whilst disease-free survival was associated with a single LNR only. The paper demonstrates the merits of utilising a data-driven approach to determining lymph node ratios from specific patient cohorts. Utilising such an approach enabled the generation of those LNRs that were most associated with particular survival trends in relation to overall and disease-free survival. These differed markedly for colon cancer, rectal cancer and combined cohorts. In general, the survival patterns associated with LNRs generated were similar to those observed with standard nodal staging.

Equipment leasing and imaging: what's going on?

In the fall of 2011, a survey of AHRA members was conducted to find out what is going on with leasing in imaging. This article discusses the survey findings as well as provides some background and definitions about leasing. Existing users of leasing are interested in becoming more sophisticated in their understanding of the economics of leasing. And non-users are seeking to learn more than just about how leases are structured. This growing interest suggests that increased utilization may be the outcome. The results of this survey were presented in detail at the Equipment Leasing and Financing Association (ELFA) Annual Convention. Attendees were encouraged to reflect on the survey results and design leasing products that satisfy the needs and requirements that the survey revealed.

Robotic versus laparoscopic right hemicolectomy: a case-matched study.

The current gold standard surgical treatment for right colonic malignancy is the laparoscopic right hemicolectomy (LRH). However, laparoscopic surgery has limitations which can be overcome by robotic surgery. The benefits of robotics for rectal cancer are widely accepted but its use for right hemicolectomy remains controversial. The aim of this study was to compare outcomes in patients undergoing robotic right hemicolectomy (RRH) and LRH in a university teaching hospital. Demographic, perioperative and postoperative data along with early oncological outcomes of patients who underwent RRH and LRH with extracorporeal anastomosis (ECA) were identified from a prospectively maintained database. A total of 70 patients (35 RRH, 35 LRH) were identified over a 4-year period. No statistically significant differences in estimated blood loss, conversion to open surgery, postoperative complications, anastomotic leak, 30-day reoperation, 30-day mortality, surgical site infection or lengths of stay were demonstrated. Surgical specimen quality in both groups was favourable. The mean duration of surgery was longer in RRH (p < < 0.00001). A statistically significant proportion of RRH patients had a higher BMI and ASA grade. The results demonstrate that RRH is safe and feasible when compared to LRH, with no statistical difference in postoperative morbidity, mortality and early oncological outcomes. A difference was noted in operating time, however was influenced by training residents in docking the robot and a technically challenging cohort of patients. Operative time has shortened with further experience. Incorporating an intracorporeal anastomosis technique in RRH offers the potential to improve outcomes compared to LRH.

Revisit, revamp, and revitalize your business plan: part 3.

Managing with financial statements is discussed, including fundamental definitions and conventions related to this process such as an income statement and a balance sheet. Balanced scorecards and dashboards can be used to measure progress and to communicate achievements. Steps taken to defining data using KPIs, sourcing data, and structuring the scorecard are outlined. A core part of managing with financial statements is understanding how to drive the business and engage the staff using balanced scorecards.

Revisit, revamp and revitalize your business plan: Part 4.

A best practice for all imaging leaders working on a management development program should be to invest enough time to complete a detailed planthatsetsgoals, objectives, step targets, landmarks, and a timetable for their achievements. Keys to success for a management development program include no surprises, active participation, and preparation by both the facilitator and the managers involved. A successful management team will have trained staff and lean processes mapped and documented, as well as be comfortable in a coaching, delegating, and consensus management style.

Visit, revamp, and revitalize your business plan: Part 2.

The diagnostic imaging department strives for the highest quality outcomes in imaging quality, in diagnostic reporting, and in providing a caring patient experience while also satisfying the needs of referring physicians. Understand how tools such as process mapping and concepts such as Six Sigma and Lean Six Sigma can be used to facilitate quality improvements and team building, resulting in staff led process improvement initiatives. Discover how to integrate a continuous staff management cycle to implement process improvements,capture the promised performance improvements, and achieve a culture change away from the "way it has always been done".

Revisit, revamp and revitalize your business plan: part 1.

The diagnostic imaging department has a pivotal role within the hospital and its pillar services. Understanding this role and also understanding the population served helps to further define and justify the "what" and "why" of the business plan. Understand the market capacity and how market needs can be satisfied. Develop a "go-to-market" strategy, which is the part of the business plan where it is decided how to share that message with the market. In the aftermath of healthcare reform and the economic recession, investing in new imaging technology has never been under greater scrutiny. A three step process for developing support is provided.

Propensity score-matched analysis comparing laparoscopic to robotic surgery for colorectal cancer shows comparable clinical and oncological outcomes.

Robotic colorectal surgery is gaining popularity. The objective of this study was to compare clinical and cancer outcomes in propensity-score matched cohorts (PSM-1:1) undergoing colorectal cancer (CRC) surgery performed using laparoscopic or robotic surgery in a single institution. A PSM cohort comparison was performed in a tertiary referral cancer and National accredited rectal cancer surgery centre. Patients with CRC undergoing laparoscopic or robotic resection with curative intent from 2016 to 2019 (inclusive) were assessed for inclusion. Matched cohorts were selected using a 1:1 ratio. Statistical analysis was performed using SPSS, version 22. 128 patients were analysed [laparoscopic (n = 64); robotic (n = 64)]. Median age was 64 years (29-84 years). 55% (n = 70) of patients were male, 45% female (n = 58). SSI rates were slightly lower in the robotic group [10.9% (n = 7) v 12.5% (n = 8) p = 0.40]. Anastomotic leak rates were equal in both groups [5.4% (n = 3)]. All but one patient received an R0 resection in each group, median LNY was 14 in the robotic group and 12 in the laparoscopic group (p = 0.004) and no difference in disease recurrence (p = 0.465) or survival (p = 0.886) was observed. Structured introduction of a robotic colorectal programme over a 3-year period has resulted in equivalent outcomes with an established laparoscopic programme for CRC.

Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence.

BACKGROUND AND AIMS: Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease. METHODS: Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells. RESULTS: Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. CONCLUSIONS: Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.

Funding technology: evaluating and exercising the leasing option.

Tax-exempt capital leases, when structured through the appropriate conduit authority, are an excellent option for financing equipment that the hospital wants to own. Operating leases offer the benefits of immediate cash flow savings when compared with buying equipment, fewer complications and lower upfront costs when compared with bond issues, and the ability to match short-term assets with short-term liabilities. A best-practice leasing process involves nine steps progressing from assessing needs and soliciting bids from equipment manufacturers to implementing the lease and providing continuing disclosure.

Respiratory Syncytial Virus Preterm (32-36 Completed Weeks of Gestation) Risk Estimation Measure for RSV Hospitalization in Ireland: A Prospective Study.

BACKGROUND: In several countries, respiratory syncytial virus prophylaxis is offered to late preterm infants who are at escalated risk of respiratory syncytial virus hospitalization (RSVH). However, targeted prophylaxis should be informed by country-specific data. This study, which uniquely includes 36 weeks of gestational age (GA) infants, aims to establish the risk factors for RSVH in 32-36 weeks of GA infants in Ireland. METHODS: A prospective observational study at 13 hospitals of laboratory-confirmed RSVH in nonprophylaxed 32-36 weeks of GA infants was conducted from July 2011 to February 2014. Baseline and first-year clinical data were analyzed by using SPSS software Version 22 (IBM Corp, Armonk, NY). Significant (P < 0.05) variables were entered into multiple logistic regression to determine the independent risk factors for RSVH. RESULTS: Sixty-three percent of eligible infants (1825 of 2877) were recruited. The RSVH rate was 3.6% (65 of 1807 analyzed infant records). There was no RSV-attributable mortality. Twelve infants required intensive care. Of the 15 variables correlating to RSVH, 5 independent risk factors were identified: older siblings [odds ratio (OR): 3.8; 95% confidence interval (CI): 1.97-7.41], being Caucasian (OR: 2.3; 95% CI: 1.04-5.29), neonatal respiratory morbidity (OR: 2.2; 95% CI: 1.28-3.94); birth July 15 to December 15 (OR: 2.1; 95% CI: 1.09-3.92) and family history of asthma (OR: 1.9; 95% CI: 1.01-3.39). Birth from 36 weeks to 36 + 6 days mitigated RSVH risk (relative risk: 0.58; 95% CI: 0.34-0.99); however, risk factors were similar to the 32-35 weeks of GA cohort. CONCLUSION: Neonatal respiratory morbidity or being Caucasian were the population-specific independent risk factors for RSVH in 32-36 weeks of GA in Ireland, whereas the other identified independent risk factors mirrored those established in previous studies.

Technology strategy and the balance sheet: 3 points to consider.

Most hospitals use technology strategically to differentiate themselves from their competition. The rapid rate of change in healthcare technologies necessitates development of a technology life-cycle management program. Having access to flexible sources of capital appropriate to each category of technology assets allows liabilities and assets to be matched on a "balanced" balance sheet.

Emergency presenting colon cancer is an independent predictor of adverse disease-free survival.

Twenty percent of colon cancers present as an emergency. However, the association between emergency presentation and disease-free survival (DFS) remains uncertain. Consecutive patients who underwent elective (CC) and emergent (eCC) resection for colon cancer were included in the analysis. Survival outcomes were compared between the 2 groups in univariate/multivariate analyses. A total of 439 patients underwent colonic resection for colon cancer during the interval 2000-2010; 97 (22.1%) presented as an emergency. eCC tumors were more often located at the splenic flexure (P = 0.017) and descending colon (P = 0.004). The eCC group displayed features of more advanced disease with a higher proportion of T4 (P = 0.009), N2 tumors (P < 0.01) and lymphovascular invasion (P< 0.01). eCC was associated with adverse locoregional recurrence (P = 0.02) and adverse DFS (P < 0.01 ) on univariate analysis. eCC remained an independent predictor of adverse locoregional recurrence (HR 1.86, 95% CI 1.50-3.30, P = 0.03) and DFS (HR 1.30, 95% CI 0.88-1.92, P = 0.05) on multivariate analysis. eCC was not associated with adverse overall survival and systemic recurrence. eCC is an independent predictor of adverse locoregional recurrence and DFS.

Metastatic breast cancer presenting as a gallstone ileus.

Metastatic breast cancer to the small bowel (SB) presenting as gallstone ileus and resulting in SB obstruction has not been described previously. A 76-year-old woman with previous metastatic breast cancer to the axial spine and hips presented with abdominal pain and bilious vomiting. CT scanning revealed SB obstruction consistent with gallstone ileus. The patient underwent two segmental SB resections for distal ileal strictures mimicking what appeared to be macroscopic Crohn's disease. The entero-biliary fistula was undisturbed. Pathological analysis revealed the dual pathologies of gallstone ileus and metastatic carcinoma from a breast primary causing luminal SB obstruction. Improvements in staging and treatment modalities have contributed to the increased overall long-term survival for breast cancer, compelling clinicians to consider metastatic breast cancer as a differential diagnosis in women presenting with new onset of gastrointestinal symptoms in order that appropriate treatment be administered in a timely fashion.

Small bowel obstruction secondary to migration of a fragment of lithobezoar: a case report.

INTRODUCTION: Small bowel obstruction is a common world-wide condition that has a range of etiological factors. The management is largely dependent on the cause of the obstruction. Small bowel obstruction caused by foreign body ingestion is rare; many items have been reported as responsible, but there are no reports implicating polyurethane foam. CASE PRESENTATION: We report the case of a 44-year-old Irish male who presented following ingestion of polyurethane foam. He was asymptomatic on presentation but developed a small bowel obstruction shortly thereafter. CONCLUSION: Patients presenting following ingestion of polyurethane foam should be scheduled for elective laparotomy, gastrotomy, and retrieval of the cast on the next available theatre list - given that they are suitable for surgery.

Clinical images. Atypical midcycle pain.

A 16-year-old female presented with acute-onset abdominal pain and an initial diagnosis of midcycle pain. Subsequent pelvic ultrasound and diagnostic laparoscopy showed a large mass in the pouch of Douglas. The patient underwent a laparotomy and excision of a mass from a loop of jejunum. This case highlights the difficulties in diagnostic differentiation relating to large pelvic masses in young females.

Experience with porcine acellular dermal collagen implant in one-stage tension-free reconstruction of acute and chronic abdominal wall defects.

BACKGROUND: Elective or emergency reconstruction of abdominal wall defects (AWD) is often difficult. Various techniques have been proposed for reconstructing AWD, including the use of synthetic implants. Porcine acellular dermal collagen (Permacol(TM)) is a biologic implant (PADCI) derived from porcine dermis. We report our experience with the use of PADCI in the management of large AWD in both emergency and elective surgery. METHODS: Twenty consecutive patients with chronic AWD (CAWD) arising from large incisional hernia or acute AWD (AAWD) arising from visceral edema or tumor resection were studied prospectively. After musculofascial mobilization, the AWD was closed using sheets (10 x 15 cm) of PADCI as an "underlay" interposition graft. Patients were followed up to a median of 18 months postoperatively. RESULTS: All 20 defects were closed without tension using PADCI. Eight and 12 patients had reconstruction for large AAWD and CAWD, respectively. The mean size of the defects was 180 cm(2) (range = 96-850 cm(2)). The median number of PADCI used to repair the defects was one sheet (range = 1-7). Twelve patients (60%) had an uneventful recovery and were discharged within seven days. One patient (5%) died from multiple-organ failure. Seven patients (35%) developed a complication (two seromas, two minor wound infections, one wound hematoma, one skin edge necrosis, one superficial wound dehiscence, and wound sinus). Overall there were three recurrences (15%). CONCLUSION: PADCI has the potential for reconstruction of large acute and chronic abdominal wall defects. Medium-term recurrence rate is comparable to synthetic mesh repairs.