Impact of preoperative opioid use disorder on outcomes following lumbar-spine surgery.

OBJECTIVES: Opioid use disorder (OUD) has previously been shown to negatively impact postoperative outcomes. As the number of spine surgeries continues to rise annually, more patients with preexisting OUD will be seen in operating rooms. Our retrospective cohort study aims to expand on the independent association between preoperative OUD and outcomes following lumbar-spine surgery. PATIENTS AND METHODS: Using 2007-2014 data from the State Inpatient Databases (SID) for the states of California (2007-2011), Florida, New York, Maryland, and Kentucky, we identified patients ≥18 years of age undergoing lumbar-spine surgery. Our primary variable of interest was present-on-admission OUD. Outcomes of interest included a range of postoperative complications divided into those specific to spinal surgery and general surgical complications, length of stay (LOS), 30- and 90-day readmission rates, and total hospital charges. RESULTS: Of the 267,976 patients undergoing lumbar-spine surgery, 1902 patients were identified as having OUD. After adjusting for patient- and hospital-level confounders, we found that patients with OUD were more likely to experience complications related specifically to spine surgery (aOR = 1.51, 95%CI = 1.33-1.71) as well as general postoperative complications (aOR = 1.63, 95%CI = 1.36-1.96) compared to those without OUD. OUD was additionally associated with longer LOS (aIRR = 1.29, CI = 1.24-1.34) and higher total charges (aIRR = 1.14, CI = 1.11-1.18). Whereas no statistically significant difference was detected for 30-day-readmission rates, patients with OUD experienced higher rates of readmission within 90 days of discharge (aOR = 1.20, CI = 1.08-1.35). CONCLUSIONS: Our study strengthens the evidence that patients with OUD fare poorly after lumbar-spine surgery. More research is needed to determine whether reducing opioid use before surgery can mitigate the postoperative risks associated with OUD.

Challenges for Students in the Creation, Growth, and Management of an Academic, Student-run Asylum Clinic.

Medical school asylum clinics are complex organizations that blend medical and legal expertise with service to assist individuals seeking refuge from human rights violations. The balance of power shared by the students and faculty who lead these clinics varies widely across institutions, usually in an inverse reciprocal relationship. The Weill Cornell Center for Human Rights will observe its 10th anniversary in 2020 and is notable for espousing maximal student autonomy in the organization's governance with minimal faculty control or administration participation. This level of autonomy requires that, in addition to successfully running the organization, student leaders must adeptly manage logistical, administrative, and ethical challenges without compromising the trust and confidence of the medical college and larger university. This article describes a series of difficult decisions involving policy, conflict resolution, and resource management made expeditiously by the student leadership. Ethical dilemmas, operational challenges, and the difficulties imposed by an unexpected global catastrophe-the COVID-19 pandemic-are presented alongside detailed descriptions of how these issues were deliberated and resolved by the student leadership.

A coding tool and abuse data for female asylum seekers.

With 1 in 3 women affected, accounting for one billion women worldwide, Violence Against Women (VAW) constitutes one of the widest reaching human rights violations globally. Although the forms they take may vary, these abuses are not confined to a single social class, geographic region, or culture. Existing studies have yet to describe the full burden of abuse that asylum-seeking women endure throughout their lifetimes. We describe a novel coding tool that classifies types of abuse, identifies abuse perpetrators, and estimates how long and how often each abuse was experienced. The authors used this tool to describe and categorize the abuses endured by 85 cisgender, adult women seeking asylum in the United States who presented to the Weill Cornell Center for Human Rights for forensic medical evaluations from 2013 to 2017. We reviewed a total of 180 legal and forensic medical affidavits that were written in support of the applicants' asylum claims. Using the coding tool, we identified each abuse, classified every perpetrator, and, whenever possible, estimated how long and how frequently each abuse was endured. Interpretations of the raw data contained in this article and a discussion of their significance can be found in our associated publication: "Gender-Based Violence experienced by Women Seeking Asylum in the United State: A Lifetime of Multiple Traumas Inflicted by Multiple Perpetrators" [1]. The coding instrument described herein characterizes VAW by classifying the narrative data that are included in interviews, focus groups, medical records, and the like. Our coding instrument is the first of its kind to describe all types and severities of violence endured by women, classify the perpetrators of that violence, and delineate the timeline of violence over each individual's life. We hope that this holistic approach to classifying and describing VAW will enable other research groups to examine untested or unrealized associations between victims, perpetrators, and abuses. Ultimately, obtaining more complete data will empower us to advocate more effectively and to design more comprehensive care for victims of VAW.

Gender-based violence experienced by women seeking asylum in the United State: A lifetime of multiple traumas inflicted by multiple perpetrators.

Estimates by the World Health Organization indicate that 1 in 3 women-more than one billion people worldwide-have experienced some form of Gender-Based Violence (GBV). Violence Against Women (VAW) is a prominent subset of GBV, defined by the United Nations as any act "that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life." VAW can include verbal harassment, physical abuse, sexual abuse, honor killing, and femicide and can occur at the hands of individuals, institutions, or states. Whereas numerous studies have documented the multiple forms of physical, sexual, and psychological violence experienced by women, a thorough characterization of the abuses experienced by asylum-seeking women in the United States has not yet been undertaken. Our analysis of the affidavits for 85 cisgender, female asylum seekers who applied for forensic medical evaluations through a student-run asylum clinic, reveals a life-long pattern of multiple types of VAW inflicted by multiple perpetrators. These findings have implications for the focus of the medico-legal documentation submitted in support of female asylum seekers as well as for the design of comprehensive healthcare services for women and girls who are granted relief.

Evaluating the Impact of Student-run Asylum Clinics in the US from 2016-2018.

Individuals applying for asylum must demonstrate a well-founded fear of persecution. By documenting signs of torture and other forms of abuse, medical evaluations can provide forensic evidence to support asylum claims. The backlog of pending immigration cases in the United States recently exceeded one million. Student-run asylum medicine clinics conduct forensic evaluations to assist in the asylum adjudication process. The Physicians for Human Rights National Student Advisory Board administered surveys to student-run clinics in the US in 2017 and 2018. Retrospective analysis evaluated the completion rates of forensic evaluations, caseload capacities, and training frequencies. Student-run asylum clinics completed 38.8% more forensic evaluations in 2017 than in 2016. In 2016, 33% of clinics received forensic evaluation requests that exceeded their capacity, a figure that rose to 50% in 2017. The number of clinicians trained by asylum clinics increased nearly fourfold between 2016 and 2017, and the number of students trained grew by 81%. A recent surge in armed conflict has contributed to record numbers of asylum applications in the US. The results of this survey reveal the burgeoning capability of student-run asylum clinics to provide evaluations, a trend that underscores medical students' ability to significantly impact human rights issues. Student-run asylum clinics are poised to fill an increasingly important role in supporting victims of torture and persecution.

Enhancement of Long-Term External-Internal Correlation by Phase-Shift Detection and Correction Based on Concurrent External Bellows and Internal Navigator Signals.

PURPOSE: The purpose of this study was to enhance the correlation between external and internal respiratory motions by dynamically determining and correcting the patient-specific phase shift between external and internal respiratory waveforms acquired concurrently during respiratory-correlated 4-dimensional magnetic resonance imaging scans. METHODS AND MATERIALS: Internal-navigator and external-bellows waveforms were acquired simultaneously during 6- to 15-minute respiratory-correlated 4-dimensional magnetic resonance imaging scans in 10 healthy participants under an institutional review board-approved protocol. The navigator was placed at the right lung-diaphragm interface, and the bellows were placed ∼5 cm inferior to the sternum. Three segments of each respiratory waveform, at the beginning, middle, and end of a scan, were analyzed. Three phase-domain methods were employed to estimate the phase shift, including analytical signal analysis, phase-space oval fitting, and principal component analysis. A robust strategy for estimating the phase shift was realized by combining these methods in a weighted average and by eliminating outliers (>2 σ) caused by breathing irregularities. Whether phase-shift correction affects the external-internal correlation was evaluated. The cross-correlation between the 2 waveforms in the time domain provided an independent check of the correlation enhancement. RESULTS: Phase-shift correction significantly enhanced the external-internal correlation in all participants across the entire 6- to 15-minute scans. On average, the correlation increased from 0.45 ± 0.28 to 0.85 ± 0.15 for the combined method. The combined method exhibited a 99.5% success rate and revealed that the phase of the external waveform leads that of the internal waveform in all 10 participants by 57 o ± 17o (1.6 ± 0.5 bins) on average. Seven participants exhibited highly reproducible phase shifts over time, evidenced by standard deviations (σ) < 4o, whereas 8o < σ < 12o in the remaining 3 participants. Regardless, phase-shift correction significantly improved the correlation in all participants. CONCLUSIONS: Correcting the phase shift estimated by the phase-domain methods provides a new approach for enhancing the correlation between external and internal respiratory motions. This strategy holds promise for improving the accuracy of respiratory-gated radiation therapy.

Homeostatic enhancement of sensory transduction.

Our sense of hearing boasts exquisite sensitivity, precise frequency discrimination, and a broad dynamic range. Experiments and modeling imply, however, that the auditory system achieves this performance for only a narrow range of parameter values. Small changes in these values could compromise hair cells' ability to detect stimuli. We propose that, rather than exerting tight control over parameters, the auditory system uses a homeostatic mechanism that increases the robustness of its operation to variation in parameter values. To slowly adjust the response to sinusoidal stimulation, the homeostatic mechanism feeds back a rectified version of the hair bundle's displacement to its adaptation process. When homeostasis is enforced, the range of parameter values for which the sensitivity, tuning sharpness, and dynamic range exceed specified thresholds can increase by more than an order of magnitude. Signatures in the hair cell's behavior provide a means to determine through experiment whether such a mechanism operates in the auditory system. Robustness of function through homeostasis may be ensured in any system through mechanisms similar to those that we describe here.

Medical Students' Attitudes toward Torture, Revisited.

This paper reports the findings of a survey of medical students' attitudes toward torture and discusses variables that may correlate with those attitudes. In late 2016, 483 enrolled medical and MD-PhD students at the Weill Cornell Medical College received an anonymous, institutional review board-approved survey that included questions about torture and its effectiveness, demographic questions, inquiries about personal experiences of harassment or discrimination, and questions regarding engagement in human rights activities. Some questions were drawn from a 2008 University of Illinois survey of medical students' attitudes toward torture, the only prior such survey at a US medical university. Of the 483 students who were contacted, 121 (25%) returned completed questionnaires, with responses indicating strong opposition to torture and skepticism about its usefulness. Respondents expressed greater opposition to torture in this survey than those who participated in the 2008 survey. Respondents' involvement in Weill Cornell's human rights program was associated with significantly stronger opposition to torture, while personal experiences of harassment were associated with a trend toward weaker opposition to torture. Respondents' answers closely approximate the clearly stated ethics of the profession, suggesting that human rights education during medical school may contribute to the development of proper values in young physicians even before they proceed into practice.

Demyelinating diseases: myeloperoxidase as an imaging biomarker and therapeutic target.

PURPOSE: To evaluate myeloperoxidase (MPO) as a newer therapeutic target and bis-5-hydroxytryptamide-diethylenetriaminepentaacetate-gadolinium (Gd) (MPO-Gd) as an imaging biomarker for demyelinating diseases such as multiple sclerosis (MS) by using experimental autoimmune encephalomyelitis (EAE), a murine model of MS. MATERIALS AND METHODS: Animal experiments were approved by the institutional animal care committee. EAE was induced in SJL mice by using proteolipid protein (PLP), and mice were treated with either 4-aminobenzoic acid hydrazide (ABAH), 40 mg/kg injected intraperitoneally, an irreversible inhibitor of MPO, or saline as control, and followed up to day 40 after induction. In another group of SJL mice, induction was performed without PLP as shams. The mice were imaged by using MPO-Gd to track changes in MPO activity noninvasively. Imaging results were corroborated by enzymatic assays, flow cytometry, and histopathologic analyses. Significance was computed by using the t test or Mann-Whitney U test. RESULTS: There was a 2.5-fold increase in myeloid cell infiltration in the brain (P = .026), with a concomitant increase in brain MPO level (P = .0087). Inhibiting MPO activity with ABAH resulted in decrease in MPO-Gd-positive lesion volume (P = .012), number (P = .009), and enhancement intensity (P = .03) at MR imaging, reflecting lower local MPO activity (P = .03), compared with controls. MPO inhibition was accompanied by decreased demyelination (P = .01) and lower inflammatory cell recruitment in the brain (P < .0001), suggesting a central MPO role in inflammatory demyelination. Clinically, MPO inhibition significantly reduced the severity of clinical symptoms (P = .0001) and improved survival (P = .0051) in mice with EAE. CONCLUSION: MPO may be a key mediator of myeloid inflammation and tissue damage in EAE. Therefore, MPO could represent a promising therapeutic target, as well as an imaging biomarker, for demyelinating diseases and potentially for other diseases in which MPO is implicated.