Long-Term Effects of Incentives for HIV Viral Suppression: A Randomized Clinical Trial.

Achieving viral suppression in people living with HIV improves their quality of life and can help end the HIV/AIDS epidemic. However, few interventions have successfully promoted HIV viral suppression. The purpose of this study was to evaluate the long-term effectiveness of financial incentives for viral suppression in people living with HIV. People living with a detectable HIV viral load (≥ 200 copies/mL) were randomly assigned to Usual Care (n = 50) or Incentive (n = 52) groups. Incentive participants earned up to $10 per day for providing blood samples with an undetectable or reduced viral load. During the 2-year intervention period, the percentage of blood samples with a suppressed viral load was significantly higher among Incentive participants (70%) than Usual Care participants (43%) (OR = 7.1, 95% CI 2.7 to 18.8, p < .001). This effect did not maintain after incentives were discontinued. These findings suggest that frequent delivery of large-magnitude financial incentives for viral suppression can produce large and long-lasting improvements in viral load in people living with HIV. ClinicalTrials.gov Identifier: NCT02363387.

Implementing contingency management into rural recovery housing: recommendations of a professional advisory expert panel.

Background: Rural areas in the United States have been severely impacted by recent rises in substance use related mortality and psychosocial consequences. There is a dearth of treatment resources to address substance use disorder (SUD). Rural recovery houses (RRH) are important services that provide individuals with SUD with an environment where they can engage in recovery-oriented activities, but dropout rates are unacceptably high, and evidence-based interventions such as contingency management (CM) may reduce dropout and improve outcomes for RRH residents. In this paper, we describe the results of a national convening of experts that addressed important issues concerning the implementation of CM within the context of RRHs.Methods: Twelve experts (five female) in the areas of CM, RRH and rural health participated in a one-day facilitated meeting that used nominal group technique to identify expert consensus in three areas as they pertain to RRH: (a) facilitators and barriers to CM implementation, (b) elements necessary for successful program building based on group feedback, and (c) recommendations for future implementation of CM.Results: Several RRH- and system-level barriers and facilitators to implementing CM were identified by the panel, and these were categorized based on the level of importance for and ease of implementation. CM funding, staff and resident buy-in, set policies, education on CM, and consistent fidelity to CM procedures and tracking were identified as important requirements for implementing CM in RRH.Conclusions: We provide recommendations for the implementation of CM in RRH that may be useful in this context, as well as more broadly.

Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial.

This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. A randomized clinical trial was conducted from 2019 to 2022. After a 1-month Induction period, 119 participants were randomly assigned to a Usual Care Control group (n = 57) or an Abstinence-Contingent Wage Supplement group (n = 62). Usual Care participants were offered counseling and referrals to employment and treatment programs. Abstinence-Contingent Wage Supplement participants could earn stipends for working with an employment specialist and wage supplements for working in a community job but had to maintain abstinence from alcohol as determined by transdermal alcohol concentration monitoring devices to maximize pay. Abstinence-Contingent Wage Supplement participants reported significantly higher rates of alcohol abstinence than Usual Care participants during the 6-month intervention (82.8% vs. 60.2% of months, OR = 3.4, 95% CI 1.8 to 6.3, p < .001). Abstinence-Contingent Wage Supplement participants were also significantly more likely to obtain employment (51.3% vs. 31.6% of months, OR = 2.6, 95% CI 1.5 to 4.4, p < .001) and live out of poverty (38.2% vs. 16.7% of months, OR = 3.7, 95% CI 2.0 to 7.1, p < .001) than Usual Care participants. These findings suggest that Abstinence-Contingent Wage Supplements can promote alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. ClinicalTrials.gov Identifier: NCT03519009.

Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials.

Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.

Characteristics and resource utilization of patients presenting to the ED from mass gathering events.

INTRODUCTION: At many mass gathering events (MGEs), emergency medical services decrease the number of patient transfers to the hospital; however, little information is known regarding the characteristics of attendees presenting to or requiring transfer to the emergency department (ED). The purpose of this study is to describe the characteristics of patients presenting from MGEs to the ED. A secondary aim of this study is to describe ED resources utilized by these patients. METHODS: This was a single-center, retrospective review evaluating patients attending MGEs who presented to the ED. Electronic medical records of patients seen in the ED of a tertiary academic medical center between October 13, 2013 and December 31, 2015 were reviewed and a descriptive analysis performed. RESULTS: We reviewed and included 209 patients. The majority of patients presenting to the ED were from large outdoor concerts (n=186, 89%), young (median age 20years), single (n=156, 87%) and had no past medical history (n=114, 63%). Alcohol use was reported in a majority (n=140, 78%) and polysubstance use in over a quarter of patients (n=55, 31%). The most frequently administered medications were intravenous fluids (n=94, 52%) and antiemetics (n=59, 33%). The majority of patients (n=161, 89%) were discharged directly from the ED, and median length of stay in the ED was 3.3h [IQR 2.3 to 5.3]. CONCLUSION: Patients presenting to the ED from MGEs generally required minimal medical care beyond supportive management with low rates of hospital admission. Further controlled studies are needed to confirm these findings.

Primate evidence on the late health effects of early-life adversity.

This paper exploits a unique ongoing experiment to analyze the effects of early rearing conditions on physical and mental health in a sample of rhesus monkeys (Macaca mulatta). We analyze the health records of 231 monkeys that were randomly allocated at birth across three rearing conditions: mother rearing, peer rearing, and surrogate peer rearing. We show that the lack of a secure attachment relationship in the early years engendered by adverse rearing conditions has detrimental long-term effects on health that are not compensated for by a normal social environment later in life.

Pitanguy Ligament Preservation in Structural Precision Rhinoplasty.

The Pitanguy ligament is a crucial structure in nasal tip support and in maintaining the integrity of the soft tissue envelope of the nose. In this cadaveric study, we dissected out the Pitanguy ligament on a series of fresh human cadaver specimens to better elucidate the structure of the ligament and its fate in open rhinoplasty. The Pitanguy ligament can act as a tethering force to the nasal tip when reshaping the nasal tip. Release of the Pitanguy ligament alleviated downward tension on the nasal tip, and tip shaping to a more appropriate position demonstrated that this ligament was displaced from its ideal position. In patients seeking rhinoplasty, this structure may require release and reconstruction to successfully alter tip position and avoid supratip deformity.

Effects of kratom on driving: Results from a cross-sectional survey, ecological momentary assessment, and pilot simulated driving Study.

OBJECTIVES: Despite widespread kratom use, there is a lack of knowledge regarding its effects on driving. We evaluated the self-reported driving behaviors of kratom consumers and assessed their simulated-driving performance after self-administering kratom products. METHODS: We present results from: 1) a remote, national study of US adults who regularly use kratom, and 2) an in-person substudy from which we re-recruited participants. In the national study (N = 357), participants completed a detailed survey and a 15-day ecological momentary assessment (EMA) that monitored naturalistic kratom use. For the remote study, outcomes were self-reported general and risky driving behaviors, perceived impairment, and driving confidence following kratom administration. For the in-person substudy, 10 adults consumed their typical kratom products and their driving performance on a high-fidelity driving simulator pre- and post-kratom administration was evaluated. RESULTS: Over 90% of participants surveyed self-reported driving under the influence of kratom. Most reported low rates of risky driving behavior and expressed high confidence in their driving ability after taking kratom. This was consistent with EMA findings: participants reported feeling confident in their driving ability and perceived little impairment within 15-180 min after using kratom. In the in-person substudy, there were no significant changes in simulated driving performance after taking kratom. CONCLUSIONS: Using kratom before driving appears routine, however, self-reported and simulated driving findings suggest kratom effects at self-selected doses among regular kratom consumers do not produce significant changes in subjective and objective measures of driving impairment. Research is needed to objectively characterize kratom's impact on driving in regular and infrequent consumers.

Male Face-Lift Finesse.

SUMMARY: Male face lifts account for approximately 10% of the total number of face-lift procedures performed annually in the United States. Although many face-lift principles apply universally, there are certain characteristics of the male face that make the management and surgical procedure unique. A systematic and patient-specific approach to the preoperative markings, facial analysis, and surgical technique in the male face lift will ensure safe, consistent, and natural appearing results.

Five-Principle and Five-Step Liquid Rhinoplasty.

SUMMARY: Liquid rhinoplasty, otherwise known as nonsurgical or filler rhinoplasty, has earned increased attention for its ability to provide surgical rhinoplasty results at a fraction of the cost and without incising the skin. However, significant complications can arise, such as tissue necrosis, filler embolus, and vascular compromise if the procedure is performed without consideration of the principles and anatomy of the face and nose. As demonstrated in this article, a stepwise and patient-specific approach to performing liquid rhinoplasty will ensure safe, consistent, and desirable results.

Role of Rib Graft for Tip Shaping in Primary Rhinoplasty: A Retrospective Case Series of 30 Patients.

PURPOSE: In primary rhinoplasty, use of harvested septal cartilage often precludes the need for rib graft. Nonetheless, there are a number of indications for the use of rib graft in primary rhinoplasty. The purpose of this study was to identify the indications and techniques for rib graft use in primary rhinoplasty. METHODS: A retrospective review was performed on all patients who underwent primary rhinoplasty by a single surgeon over a 5-year period. From these patients, those who required the use of fresh frozen allograft rib cartilage were identified. Medical record review was performed to identify demographics, ethnicity, and history of nasal trauma. Photographic analysis was also performed. RESULTS: Thirty (4.7%) of 638 consecutive primary rhinoplasties required rib graft. Of these, 7 patients (23.3%) demonstrated a history of nasal trauma. Further, a high proportion of primary rhinoplasty patients requiring rib graft were from Asian (n=7, 23.3%), Middle Eastern (n=4, 13.3%), Hispanic (n=7, 23.3%), and African American (n=9, 30%) backgrounds. Caucasian patients were in the minority (n=2, 6.7%). All primary rhinoplasties utilizing rib graft implemented a septal extension graft. CONCLUSION: The present study demonstrates that patients requiring a rib graft in primary rhinoplasty invariably receive a septal extension graft. Further, certain ethnicity associated anatomical characteristics correlated with the need for a rib graft for tip shaping. Ultimately, the use of a septal extension graft in primary rhinoplasty allows for precise and robust projection, rotation, and tip shaping in noses with thick skin, weak cartilaginous framework, and history of nasal trauma.

Soft Tissue Filler for Secondary Nasal Deformities.

SUMMARY: One common indication for soft tissue filler in the nose, or "liquid rhinoplasty," is the temporary treatment of secondary nasal deformities after rhinoplasty. When applied in this manner, there are multiple aspects of the patient evaluation, timing with respect to the prior rhinoplasty and planned revision, and procedural principles and steps that must be carefully considered. Ultimately, when appropriately implemented, the procedure can help avoid unnecessary patient angst and displeasure preceding a formal revision rhinoplasty. The following article reviews the principles and application of soft tissue filler for secondary nasal deformities.

Enhanced Recovery After Surgery: Standardized Postoperative Instructions in Hand Surgery.

Background: Enhanced Recovery After Surgery (ERAS) is a standardized approach to care of the surgical patient. Postoperative patient instructions, an aspect of ERAS protocols, are difficult to standardize in hand surgery because of the diversity of procedures. The aim of this study was to determine the effect of standardized hand surgery postoperative instructions on the number of unscheduled postoperative patient encounters. Methods: The study was an institutional review board-approved prospective cohort in which all hand surgery patients from 6 surgeons at a single, hospital-based academic institution were included. For a 6-month period, both before and after establishing a standardized postoperative instructional handout, data were collected on unscheduled postoperative encounters within 14 days of surgery. Results: There were 330 patients in the control group versus 282 who received standardized postoperative instructions. Trauma comprised 24.6% of cases in comparison to 75.4% elective. Individual surgeons did not significantly influence whether patients had an encounter. Overall, patients who received standardized instructions were just as likely as the control group to have unscheduled encounters (41.5% vs 43.9%, respectively). Notably, elective patients were significantly more likely to have encounters (46%) versus trauma patients (33.1%; P = .007); however, the standardized instructions did not influence the number of encounters for either group. Conclusions: This study did not demonstrate a difference in unscheduled postoperative encounters after initiation of standardized postoperative instructions for hand surgery patients. These findings may help providers save time and resources by tailoring the use of ERAS in this distinct patient population.

Techniques in Facial Fat Grafting: Optimal Results Based on the Science of Facial Aging.

SUMMARY: A thorough understanding of the science of facial aging is imperative to the precise and natural restoration of a youthful appearance. A hallmark of the aging process is fat atrophy. For this reason, fat grafting has become a keystone of the modern face lift. As a result, fat-grafting techniques have been refined to achieve optimal results. This is done through the differential use of fractionated and unfractionated fat throughout the face. This article reviews a single surgeon's technique for achieving optimal results in facial fat grafting.

Refinements in Extended Alar Contour Grafts: Retrograde Approach in Conjunction with Alar Base Surgery.

SUMMARY: Alar contour grafts are an excellent adjunct in both primary and revision rhinoplasty for correction and prevention of alar rim irregularities. They are traditionally placed at the conclusion of a rhinoplasty through a vestibular incision along the underside of the alar rim. Alternatively, alar base resection provides an opportunity for precise retrograde placement of alar contour grafts. The purpose of this article is to describe an efficient, five-step technique for retrograde placement of alar contour grafts in the setting of concomitant alar base surgery.

Beyond Alar Base Resection: Contouring of the Alar Rim and Base.

SUMMARY: Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Impact of Age, Body Mass Index, and Resection Weight on Postoperative Complications in Reduction Mammaplasty.

BACKGROUND: The authors seek to evaluate the impact of age, body mass index (BMI), and resection weight, on postoperative complications in women undergoing primary bilateral reduction mammaplasty. METHODS: A retrospective review of all primary bilateral reduction mammaplasties between February of 2014 and August of 2018 was performed. Patient demographics, medical comorbidities, tobacco use, BMI, operative technique, operative time, resection weight, and complications were reviewed. RESULTS: Two hundred seventy-seven women were included. Mean age was 35.71 years, and BMI was 30.17 kg/m 2 . An inferior pedicle (53.07%) with Wise pattern resection (53.43%) was used most commonly. The minor complication rate was 49.1%, with superficial wounds (42.1%) occurring most commonly. Thirty-three women (11.9%) required greater than 2 months to heal. The major complication rate was 4.31%. BMI was not associated with minor or major complications on univariate analysis ( P = 0.1003 and P = 0.6163), but was associated with wound healing requiring greater than 2 months ( P = 0.0009), longer operative times ( P = 0.0002), and higher resection weights ( P < 0.00001). Greater age was associated with higher minor complication rates ( P = 0.0048). On multivariate analysis, BMI was associated with wound healing requiring greater than 2 months ( P = 0.0137), and age with minor complications ( P = 0.0180). No factors impacted major complication rates. CONCLUSIONS: Women with higher BMI are more likely to require larger resections, longer operative times, and are at higher risk for wound healing requiring greater than 2 months. Although BMI is an important consideration for determining operative candidacy, the benefits of reduction may outweigh these risks in carefully selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Cost and cost-effectiveness of abstinence contingent wage supplements.

BACKGROUND: Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care. METHODS: To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment. RESULTS: ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915. CONCLUSIONS: ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.

Kinematics of reaching and implications for handedness in rhesus monkey infants.

Kinematic studies of reaching in human infants using two-dimensional (2-D) and three-dimensional (3-D) recordings have complemented behavioral studies of infant handedness by providing additional evidence of early right asymmetries. Right hand reaches have been reported to be straighter and smoother than left hand reaches during the first year. Although reaching has been a popular measure of handedness in primates, there has been no systematic comparison of left and right hand reach kinematics. We investigated reaching in infant rhesus monkeys using the 2-D motion analysis software MaxTRAQ Lite+ (Innovision Systems). Linear mixed-effects models revealed that left hand reaches were smoother, but not straighter, than right hand reaches. An early left bias matches previous findings of a left hand preference for reaching in adult rhesus monkeys. Additional work using this kind of kinematic approach will extend our understanding of primate handedness beyond traditional studies measuring only frequency or bouts of hand use.

Safety and Efficacy of Transform for Noninvasive Lipolysis and Circumference Reduction of the Abdomen.

Noninvasive body contouring has seen a precipitous rise in popularity since its advent in the early 2000s. With this rise in popularity, there has been an expansion in the types and number of noninvasive devices for muscle hypertrophy and fat lipolysis. The Transform radiofrequency and electrical muscle stimulation device is a newly introduced device for noninvasive abdominal body contouring. The present study is a prospective clinical trial evaluating the efficacy of the Transform device on abdominal circumference. Fifteen patients were enrolled and received three treatment sessions with the Transform device. On average, patients saw changes in abdominal circumference (-0.43 cm, P = 0.48), caliper pinch thickness (-6.07 mm, P = 0.0036), and ultrasound fat thickness (-5.40 mm, P < 0.001) at 3 months posttreatment with minimal discomfort and high patient satisfaction. Ultimately, this study demonstrates that the Transform device is a safe and effective noninvasive option for fat lipolysis and muscular hypertrophy.