Lessons Learned From the Implementation of an Integrated Prenatal Opioid Use Disorder Program.

OBJECTIVE: To evaluate key lessons learned from efforts at increasing engagement in integrated prenatal and opioid use disorder services. DESIGN: An interdisciplinary team consisting of a board-certified obstetrician and registered nurse led the implementation of this multipronged approach driven by several plan-do-study-act cycles to develop an integrated prenatal and opioid use disorder program. SETTING/LOCAL PROBLEM: An urban community health center in Chicago, Illinois, where mental health issues, including substance use, are the leading cause of death for pregnant people. PARTICIPANTS: Connections were made with local harm reduction agencies, substance use treatment facilities, and community outreach programs to develop partnerships with organizations providing existing addiction and maternal-child services in the community. INTERVENTION/MEASURES: Partnership building was achieved through organization needs assessments, dissemination of information about integrated services, and sustained communication. Referral workflow guides and patient education cards were created and distributed to community partners. Incoming referrals were tracked at the clinic site. Use of the referral materials was evaluated via online surveys distributed to community partners. RESULTS: In the 18 weeks of enhanced integration, three patients engaged in services and were initiated on medication for opioid use disorder, two of whom had been referred from agencies targeted in the outreach efforts. Surveys showed that community partners believe the referral guides were easy to use and that the harm reduction information on the patient cards was useful. CONCLUSION: An urban community health center was equipped to provide comprehensive, integrated services to pregnant people with opioid use disorder, but barriers such as community unawareness and stigma impeded engagement. Sustained collaboration with community partners serving pregnant people with opioid use disorder supports program development and linkage to care. Integrated prenatal and opioid use disorder care is feasible, is destigmatizing in nature, and can lead to improved maternal and fetal outcomes.

Replacing Computed Tomography with "Rapid" Magnetic Resonance Imaging for Ventricular Shunt Imaging.

INTRODUCTION: Children with ventricular shunts undergo frequent neuroimaging, and therefore, radiation exposures, to evaluate shunt malfunctions. The objective of this study was to safely reduce radiation exposure in this population by reducing computed tomography (CT) and increasing "rapid" magnetic resonance imaging (rMRI-shunt) among patients warranting neuroimaging for possible shunt malfunction. METHODS: This was a single-center quality improvement study in a tertiary care pediatric emergency department (ED). We implemented a multidisciplinary guideline for ED shunt evaluation, which promoted the use of rMRI-shunt over CT. We included patients younger than 18 years undergoing an ED shunt evaluation during 11 months of the preintervention and 25 months of the intervention study periods. The primary outcome was the CT rate, and we evaluated the relevant process and balancing measures. RESULTS: There were 266 encounters preintervention and 488 during the intervention periods with similar neuroimaging rates (80.7% versus 81.5%, P = 0.8.) CT decreased from 90.1% to 34.8% (difference -55.3%, 95% confidence interval [CI]: -71.1, -25.8), and rMRI-shunt increased from 9.9% to 65.2% (difference 55.3%, 95% CI: 25.8, 71.1) during the preintervention and intervention periods, respectively. There were increases in the mean time to neuroimaging (53.1 min; [95% CI: 41.6, 64.6]) and ED length of stay (LOS) (52.3 min; [95% CI: 36.8, 67.6]), without changes in total neuroimaging, 72-hour revisits, or follow-up neuroimaging. CONCLUSIONS: Multidisciplinary implementation of a standardized guideline reduced CT and increased rMRI-shunt use in a pediatric ED setting. Clinicians should balance the reduction in radiation exposure with ED rMRI-shunt for patients with ventricular shunts against the increased time of obtaining imaging and LOS.

The Current Status of the Autologous Fat Grafting for Pediatric Craniofacial Patients.

Since its first introduction, autologous fat grafting (AFG) has undergone multiple refinements and has become a common treatment option within plastic surgery. It is a safe, quick, economical, and minimally invasive method for volume augmentation and is finding its own indications in the pediatric craniofacial surgery patients. Because there is currently a paucity of literature regarding the use of AFG in the pediatric population compared with the adults, the authors performed a systematic review of the literature using PubMed, Cochrane Library databases, and the Journal of Plastic and Reconstructive Surgery using the terms of fat grafting/lipofilling, fat grafting, and craniofacial surgery to include articles that contained pediatric patients. While reviewing AFG in the pediatric craniofacial patients, indications, technique, and challenges were specifically evaluated and an algorithm of approach was proposed. In current practice, the choice of microvascular free flap versus AFG is one of the surgeon preferences on a case-by-case basis. With the low complication rate and ease of use, selection of AFG for the repair of soft tissue defects in pediatric craniofacial patients is increasing and may come to surpass use of traditional invasive methods such as free flaps. It should also be considered as a useful adjunct to other concurrent invasive procedures, that is, bony adjustments.

ABCA7 haplodeficiency disturbs microglial immune responses in the mouse brain.

Carrying premature termination codons in 1 allele of the ABCA7 gene is associated with an increased risk for Alzheimer's disease (AD). While the primary function of ABCA7 is to regulate the transport of phospholipids and cholesterol, ABCA7 is also involved in maintaining homeostasis of the immune system. Since inflammatory pathways causatively or consequently participate in AD pathogenesis, we studied the effects of Abca7 haplodeficiency in mice on brain immune responses under acute and chronic conditions. When acute inflammation was induced through peripheral lipopolysaccharide injection in control or heterozygous Abca7 knockout mice, partial ABCA7 deficiency diminished proinflammatory responses by impairing CD14 expression in the brain. On breeding to AppNL-G-F knockin mice, we observed increased amyloid-ß (Aß) accumulation and abnormal endosomal morphology in microglia. Taken together, our results demonstrate that ABCA7 loss of function may contribute to AD pathogenesis by altering proper microglial responses to acute inflammatory challenges and during the development of amyloid pathology, providing insight into disease mechanisms and possible treatment strategies.

Survey of Parent Experiences in Prenatal Visits for Infants With Cleft Lip and Palate.

OBJECTIVE: The purpose of this study was to identify the factors that influence the parent's choice of cleft team/surgeon. DESIGN: A 10-question survey was used to elucidate factors that influenced parents in choosing their cleft surgeon. No identifiers of the origin of the study were used to improve parent objectivity. SETTING: The setting for this study was an online survey. PARTICIPANTS: Participants in this study were the parents of children who were born with cleft lip and/or palate. INTERVENTIONS: Parents were contacted anonymously via national, established social media websites that were independently run by the parents themselves. MAIN OUTCOME MEASURES: The main outcome measures were information regarding choice of cleft team/surgeon, source of patient referrals, and use of online media in decision making. RESULTS: A total of 112 responses were received. Of the parents, 77% sought prenatal evaluation with at least one cleft surgeon. Maternal-fetal medicine specialists were the most frequent (42%) referral source, followed by primary obstetricians (14%) and pediatricians (12%). The surgeon/cleft team's experience level and overall personality were ranked as the most important, whereas the least important was distance traveled. Of the parents, 95% used the Internet or social media for research prior to their prenatal visit; 96% of the parents found the prenatal visit helpful, and the most useful topics discussed were treatments (surgical, nonsurgical) and feeding techniques. CONCLUSION: This study identifies factors used to choose a cleft team/surgeon. Parents are more concerned with the experience level, reputation, and environment of the cleft team/surgeon than the distance traveled to get to the center.

Portal vein thrombosis after laparoscopic cholecystectomy.

INTRODUCTION: Portal vein thrombosis (PVT) is a relatively uncommon complication after abdominal surgery. CASE REPORT: We report an even more unusual case of PVT 10 days after an uncomplicated laparoscopic cholecystectomy, believed to be only the fourth reported case in the literature of this rare complication. CONCLUSION: Albeit extremely rare, PVT should be included in the differential diagnosis for abdominal symptoms and/or elevated hepatic function tests after laparoscopic cholecystectomy.