A magnetic massive star has experienced a stellar merger.

Massive stars (those ≥8 solar masses at formation) have radiative envelopes that cannot sustain a dynamo, the mechanism that produces magnetic fields in lower-mass stars. Despite this, approximately 7% of massive stars have observed magnetic fields, the origin of which is debated. We used multi-epoch interferometric and spectroscopic observations to characterize HD 148937, a binary system of two massive stars. We found that only one star is magnetic and that it appears younger than its companion. The system properties and a surrounding bipolar nebula can be reproduced with a model in which two stars merged (in a previous triple system) to produce the magnetic massive star. Our results provide observational evidence that magnetic fields form in at least some massive stars through stellar mergers.

Pursuing Scholarship: Creating Effective Conference Submissions.

Medical educators are expected to disseminate peer-reviewed scholarly work for academic promotion and tenure. However, developing submissions for presentations at national meetings can be confusing and sometimes overwhelming. Awareness and use of some best practices can demystify the process and maximize opportunities for acceptance for a variety of potential submission categories. This article outlines logistical steps and best practices for each stage of the conference submission process that faculty should consider when preparing submissions. These include topic choice, team composition, consideration of different submission types, and strategies for effectively engaging participants.

Internal border zone injury predicts the functional outcome of acute MCA stroke patients.

BACKGROUND AND PURPOSE: Classification of deep (D), superficial (S) MCA territories and their junctional vascular area (the internal border zone, IBZ) can help to identify patients most likely to benefit from aggressive reperfusion therapy after stroke. We tested the prognostic value of an IBZ injury compared to DWI-ASPECTS and infarct volume. MATERIALS AND METHODS: DW lesions of 168 patients with acute (4.2±6.5 h) MCA strokes were retrospectively examined and manually delineated. Patients with haemorrhagic transformation or other neurological diseases were excluded. Clinical data were recorded within 24 h following symptom onset and 48 h for patients who benefited from reperfusion therapy. The occurrence of an IBZ injury was determined using a standardized stereotaxic atlas. Performance to predict a good outcome (mRS<3 at 3 months) was estimated through ROC curves for DWI-ASPECTS≤6, lesion volume≥100 mL and IBZ injury. Logistic regression models were performed to estimate independent outcomes for infarct volume and IBZ injury. RESULTS: Infarcts involving the IBZ were larger (94.9±98.8 mL vs. 30.2±31.3 mL), had higher NIHSS (13.8±7.2 vs. 7.2±5.7), more frequent MCA occlusions (64.9% vs. 28.3%), and worse outcomes (mRS 3.0±1.8 vs. 1.9±1.7), and were less responsive to IVtPA (34±47% vs. 55±48% of NIHSS improvement). The area under the ROC curves was comparable between the occurrence of IBZ injury (0.651), ASPECTS≤6 (0.657) and volume≥100 mL (0.629). Logistic regression analyses showed an independent effect of an IBZ injury, especially for superficial MCA strokes and for patients who benefited from reperfusion therapy. CONCLUSION: An IBZ injury is an early and independent marker of stroke severity, functional prognosis and treatment responsiveness.

Finite Element Model of a Piezo-Electric Actuator Coupled to the Middle Ear.

The hearing contact lens® (HCL) is a new type of hearing aid devices. One of its main components is a piezo-electric actuator. In order to evaluate and maximize the HCL's performance, a model of the HCL coupled to a middle-ear model was developed using finite element approach. The model was validated step by step starting with the HCL only. To validate the HCL model, vibrational measurements on the HCL were performed using a laser-doppler-vibrometer (LDV). Then, a silicone cap was placed onto the HCL to provide an interface between the HCL and the tympanic membrane of the middle-ear model, and additional LDV measurements on temporal bones were performed to validate the coupled model that was used to evaluate the equivalent sound pressure of the HCL. Moreover, a de-eper insight was gained into the contact between the HCL and tympanic membrane and its effects on the HCL performance. The model can be used to investigate the sensitivity of geometrical and material parameters with respect to performance measures of the HCL and evaluate the feedback behavior.

Diffusion and interaction dynamics of the cytosolic peroxisomal import receptor PEX5.

Cellular functions rely on proper actions of organelles such as peroxisomes. These organelles rely on the import of proteins from the cytosol. The peroxisomal import receptor PEX5 takes up target proteins in the cytosol and transports them to the peroxisomal matrix. However, its cytosolic molecular interactions have so far not directly been disclosed. Here, we combined advanced optical microscopy and spectroscopy techniques such as fluorescence correlation spectroscopy and stimulated emission depletion microscopy with biochemical tools to present a detailed characterization of the cytosolic diffusion and interaction dynamics of PEX5. Among other features, we highlight a slow diffusion of PEX5, independent of aggregation or target binding, but associated with cytosolic interaction partners via its N-terminal domain. This sheds new light on the functionality of the receptor in the cytosol as well as highlighting the potential of using complementary microscopy tools to decipher molecular interactions in the cytosol by studying their diffusion dynamics.

Intrinsic Dimensionality as a Metric for the Impact of Mission Design Parameters.

High-resolution space-based spectral imaging of the Earth's surface delivers critical information for monitoring changes in the Earth system as well as resource management and utilization. Orbiting spectrometers are built according to multiple design parameters, including ground sampling distance (GSD), spectral resolution, temporal resolution, and signal-to-noise ratio. Different applications drive divergent instrument designs, so optimization for wide-reaching missions is complex. The Surface Biology and Geology component of NASA's Earth System Observatory addresses science questions and meets applications needs across diverse fields, including terrestrial and aquatic ecosystems, natural disasters, and the cryosphere. The algorithms required to generate the geophysical variables from the observed spectral imagery each have their own inherent dependencies and sensitivities, and weighting these objectively is challenging. Here, we introduce intrinsic dimensionality (ID), a measure of information content, as an applications-agnostic, data-driven metric to quantify performance sensitivity to various design parameters. ID is computed through the analysis of the eigenvalues of the image covariance matrix, and can be thought of as the number of significant principal components. This metric is extremely powerful for quantifying the information content in high-dimensional data, such as spectrally resolved radiances and their changes over space and time. We find that the ID decreases for coarser GSD, decreased spectral resolution and range, less frequent acquisitions, and lower signal-to-noise levels. This decrease in information content has implications for all derived products. ID is simple to compute, providing a single quantitative standard to evaluate combinations of design parameters, irrespective of higher-level algorithms, products, applications, or disciplines.

Adverse Childhood Experiences and Diabetes: Testing Violence and Distress Mediational Pathways in Family Medicine Patients.

Type 2 diabetes mellitus (diabetes) is increasing in frequency and creating a significant burden on the United States healthcare system. Adverse childhood experiences (ACE) and interpersonal violence (IV) have been shown to have detrimental effects on mental and physical health. How ACE can influence IV as an adult and how this can influence the management of diabetes is not known. The purpose of the current study is to understand the relationship between violence and social determinants of health (SDoH), and its effect on patients with type 2 diabetes mellitus. A practiced-based research network (PBRN) of family medicine residency programs was utilized to collect cross-sectional data from seven family medicine residency program primary care clinics. In total, 581 participants with type 2 diabetes were recruited. A serial/parallel mediation model were analyzed. The majority of participants (58.3%) had a Hemoglobin A1c (HbA1c) that was not controlled. ACE was associated with an increase in Hurt-Insult-Threaten-Scream (HITS) scores, which in turn was positively associated with an increase in emotional burden, and finally, emotional burden decreased the likelihood that one's HbA1c was controlled (Effect = -.054, SE = .026 CI [-.115, -.013]). This indirect pathway remained significant even after controlling for several SDoH and gender. The impact of ACE persists into adulthood by altering behaviors that make adults more prone to experiencing family/partner violence. This in turn makes one more emotionally distressed about their diabetes, which influences how people manage their chronic condition. Family physicians should consider screening for both ACE and family/partner violence in those patients with poorly controlled diabetes.

The effect of potent CYP2D6 inhibition on the pharmacokinetics and safety of deutetrabenazine in healthy volunteers.

PURPOSE: Deutetrabenazine is a deuterated form of tetrabenazine with a confirmed lower rate of CYP2D6 metabolism of the active metabolites, α- and ß-HTBZ. In this study, we assessed the effect of paroxetine, a potent CYP2D6 inhibitor, on the pharmacokinetics and safety of deutetrabenazine and its metabolites. METHODS: In this open-label sequential drug-drug-interaction study, 24 healthy adults who were CYP2D6 extensive or intermediate metabolizers received a single deutetrabenazine 22.5-mg oral dose on days 1 and 11 and a single paroxetine 20-mg oral daily dose on days 4-12. Pharmacokinetics of deutetrabenazine and its metabolites were assessed on days 1-4 and 11-14. Paroxetine trough concentrations were obtained pre-dose on days 9-13. Safety examinations occurred throughout the study. RESULTS: Paroxetine administered under steady-state conditions, increased exposure of the deuterated active metabolites, α-HTBZ (1.2-fold Cmax and 1.8-fold AUC0-∞) and ß-HTBZ (2.1-fold Cmax and 5.6-fold AUC0-∞), and correspondingly, 1.6-fold Cmax and threefold AUC0-∞ for total (α + ß)-HTBZ. Sixteen subjects reported 45 adverse events and most were mild. Headache was the most common AE reported 8 times by 7 subjects (5 following paroxetine alone; 2 following deutetrabenazine + paroxetine). CONCLUSIONS: Paroxetine-induced increases in exposure to the active deutetrabenazine metabolites were less than those previously reported for tetrabenazine, a finding expected to reduce the burden of drug interaction. In addition, single doses of 22.5 mg deutetrabenazine, when given alone or in the presence of steady-state paroxetine (20 mg daily), were safe.

Increased Smoking Cessation Among Veterans With Large Decreases in Posttraumatic Stress Disorder Severity.

INTRODUCTION: Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. AIMS AND METHODS: Veterans Health Affairs (VHA) medical record data (2008-2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2 years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. RESULTS: On average, patients were 39.4 (SD = 12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with versus without clinically meaningful PTSD improvement stopped smoking (n = 36, cumulative incidence = 40.5% vs. 111, cumulative incidence = 30.8%, respectively). After controlling for confounding, patients with versus without clinically meaningful PTSD improvement were more likely to stop smoking within 2 years (hazard ratio = 1.57; 95% confidence interval: 1.04-2.36). CONCLUSIONS: Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. IMPLICATIONS: Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking-related disease.

Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination.

OBJECTIVES: The purpose of this study was to examine the perspectives of primary care physicians in Texas around vaccine acceptance and potential patient barriers to vaccination. National surveys have shown fluctuating levels of acceptance for COVID-19 vaccination, and primary care physicians could play a crucial role in increasing vaccine uptake. DESIGN: This study employed a cross-sectional anonymous survey design to collect data using an online questionnaire. Participants were asked about vaccination practices and policies at their practice site, perceptions of patient and community acceptance and confidence in responding to patient vaccine concerns. SETTING: From November 2020 to January 2021, family medicine physicians and paediatricians completed an online questionnaire on COVID-19 vaccination that was distributed by professional associations. PARTICIPANTS: The survey was completed by 573 practising physicians, the majority of whom identified as family medicine physicians (71.0%) or paediatricians (25.7%), who are currently active in professional associations in Texas. RESULTS: About three-fourths (74.0%) of participants reported that they would get the vaccine as soon as it became available. They estimated that slightly more than half (59.2%) of their patients would accept the vaccine, and 67.0% expected that the COVID-19 vaccine would be accepted in their local community. The majority of participants (87.8%) reported always, almost always or usually endorsing vaccines, including high levels of intention to recommend COVID-19 vaccination (81.5%). Participants felt most confident responding to patient concerns related to education about vaccine types, safety and necessity and reported least confidence in responding to personal or religious objections to COVID-19 vaccination. CONCLUSIONS: The majority of the physicians surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were confident in their ability to respond to patient concerns. With additional education, support and shifting COVID-19 vaccinations into primary care settings, primary care physicians can use the trust they have built with their patients to address vaccine hesitancy and potentially increase acceptance and uptake.

Sustainable Development Goals and livestock systems.

Within the framework of the Sustainable Development Goals (SDGs) of the United Nations, particularly those that livestock impact most significantly (SDGs 1, 2, 3, 5, 8, 12, 13, 15 and 17), this paper provides an overview of the livestock sector's impact on food system sustainability and opportunities for building solutions through sustainable livestock options that are supported by robust animal health services. The discourse is shaped by the experiences of the Global Agenda for Sustainable Livestock, a multi-stakeholder partnership which facilitates policy dialogue and action among diverse stakeholders to make livestock systems more sustainable. The Global Agenda for Sustainable Livestock adopted the aforementioned SDGs as the reference framework for its actions, which are organised under four domains (food and nutrition security, animal health and welfare, livelihoods and economic growth, and climate and natural resources). These domains are used to highlight the complexity and diversity of the livestock sector, its positive and negative relationships to development, the integral roles of animal health systems and the opportunities for livestock sector contributions towards a sustainable future.

Se plaçant dans la perspective des objectifs de développement durable (ODD) des Nations unies et plus particulièrement ceux sur lesquels l'élevage exerce le plus grand impact (ODD 1, 2, 3, 5, 8, 12, 13, 15 et 17), les auteurs font un tour d'horizon de l'impact du secteur de l'élevage sur la durabilité des systèmes d'approvisionnement alimentaire et font ressortir les solutions qui peuvent être envisagées en mettant en place des pratiques d'élevage durables soutenues par des services de santé animale robustes. L'exposé est structuré par les expériences acquises dans le cadre du Programme mondial pour un élevage durable, un partenariat multipartite qui facilite le dialogue politique entre diverses parties prenantes ainsi que les mesures visant à rendre les systèmes d'élevage plus durables. Le Programme mondial a intégré les ODD susmentionnés en tant que cadre de référence de ses interventions, qui se répartissent en quatre domaines (alimentation et sécurité nutritionnelle, santé et bien-être des animaux, moyens de subsistance et croissance économique, climat et ressources naturelles). Ces domaines permettent de souligner la complexité et la diversité du secteur de l'élevage, ses liens positifs et négatifs au regard du développement, le rôle prépondérant des systèmes de santé animale et les perspectives offertes au secteur de l'élevage pour contribuer à un futur durable.

Situándose en el perspectiva de los Objetivos de Desarrollo Sostenible (ODS) de las Naciones Unidas, en especial de aquellos en los que más influye la ganadería (ODS 1, 2, 3, 5, 8, 12, 13, 15 y 17), los autores exponen a grandes líneas el impacto del sector ganadero en la sostenibilidad del sistema alimentario y las oportunidades que existen para elaborar soluciones que pasen por actuar sobre el sector ganadero con el apoyo de robustos servicios zoosanitarios. La reflexión se fundamenta en la experiencia del Programa mundial para una ganadería sostenible, alianza multipartita que facilita la acción conjunta y el diálogo sobre políticas de diversas partes interesadas con objeto de hacer más sostenibles los sistemas ganaderos. El Programa mundial adoptó los mencionados ODS como marco de referencia de sus actividades, que están organizadas en cuatro ámbitos: seguridad alimentaria y de la nutrición; sanidad y bienestar animales; medios de sustento y crecimiento económico; y clima y recursos naturales. Estos ámbitos sirven para poner de relieve la complejidad y diversidad del sector ganadero, sus nexos positivos y negativos con el desarrollo, las funciones integrales que cumplen los sistemas de sanidad animal y las posibilidades existentes para que el sector ganadero contribuya a forjar un futuro sostenible.

Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion.

PURPOSE: Faculty promotion is important for retention and has implications for diversity. This study provides an update on recent trends in faculty promotion in U.S. medical schools. METHOD: Using data from the Association of American Medical Colleges Faculty Roster, the authors examined trends in faculty promotion over 10 years. Promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 inclusive was followed from January 1, 2010 to January 1, 2019. The authors used bivariate analyses to assess associations and promotion rates by sex, race/ethnicity, department, tenure status, and degree type. RESULTS: The promotion rate for assistant professors was 44.3% (2,330/5,263) in basic science departments, 37.1% (17,232/46,473) in clinical science departments, and 33.6% (131/390) in other departments. Among clinical departments, family medicine had the lowest rate of promoting assistant professors (24.4%; 484/1,982) and otolaryngology the highest rate (51.2%; 282/551). Faculty members who were male (38.9%; 11,687/30,017), White (40.0%; 12,635/31,596), tenured (58.7%; 98/167) or tenure-eligible (55.6%; 6,653/11,976), and holding MDs/PhDs (48.7%; 1,968/4,038) had higher promotion rates than, respectively, faculty who were female (36.3%; 7,975/21,998), minorities underrepresented in medicine (URM; 31.0%; 1,716/5,539), nontenured (32.5%; 12,174/37,433), and holding other/unknown degrees (20.6%; 195/948; all P < .001). These differences were less pronounced among associate professors; however, URM and nontenured faculty continued to have lower promotion rates compared with White, Asian, or tenured faculty at the associate professor level. CONCLUSIONS: Promotion rates varied not only by faculty rank but also by faculty sex, race/ethnicity, department, tenure status, and degree type. The differences were more pronounced for assistant professors than associate professors. URM faculty members, particularly assistant professors, were promoted at lower rates than their White and Asian peers. More research to understand the drivers of disparities in faculty promotion seems warranted.

Emergency department presentation of opioid use disorder and alcohol use disorder.

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

Identifying and overcoming barriers to trauma screening in the primary care setting.

Introduction: Underrecognition of trauma exposure and PTSD has a significant impact on psychiatric health, physical health, and health behaviors. The purpose of this study is to explore barriers and opportunities for trauma screening in primary care. Methods: Primary care physicians (PCPs) and their patients were interviewed about the acceptability of trauma screening and brief treatment in primary care. Interview transcripts were coded and analyzed for themes using Atlas v. 7.0. Results: Data showed PCPs informally screen for trauma but were hampered by organizational constraints including time, availability of behavioral health providers, and knowledge of trauma-informed-care practices. Most patients with trauma history met with behavioral health providers during their lifetimes, but still did not believe it was the PCPs' role to address trauma exposure, had fears of "appearing crazy," or were ambivalent about seeking treatment. Discussion: Findings suggest an enormous complexity involved in screening for trauma in primary care service delivery. Trauma screening appears to work best within the course of relationship building where patients can begin to see that their physician is capable of playing an important role in managing trauma, depression, and PTSD symptoms. We address how trauma discussion can take place within existing trauma informed care guidelines. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A short-term musical training affects implicit emotion regulation only in behaviour but not in brain activity.

BACKGROUND: In everyday life, negative emotions can be implicitly regulated by positive stimuli, without any conscious cognitive engagement; however, the effects of such implicit regulation on mood and related neuro-mechanisms, remain poorly investigated in literature. Yet, improving implicit emotional regulation could reduce psychological burden and therefore be clinically relevant for treating psychiatric disorders with strong affective symptomatology. RESULTS: Music training reduced the negative emotional state elicited by negative odours. However, such change was not reflected at the brain level. CONCLUSIONS: In a context of affective rivalry a musical training enhances implicit regulatory processes. Our findings offer a first base for future studies on implicit emotion regulation in clinical populations.

PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data.

BACKGROUND: Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization. METHODS: We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits. RESULTS: The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits. CONCLUSIONS: Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.

The association of opioid use duration and new depression episode among patients with and without insomnia.

OBJECTIVE: Insomnia commonly co-occurs with depression, chronic pain, and opioid use. Both insomnia and chronic opioid analgesic use (OAU) are independent risk factors for a new depression episode (NDE). This study determined if the association between longer OAU duration and NDE was stronger in those with versus without insomnia. DESIGN: Retrospective cohort. SETTING: Veterans Health Administration electronic medical records (2000-2012). PARTICIPANTS: New opioid users in follow-up (2002-2012), free of depression for two years prior to follow-up, and aged 18-80 (n = 70,997). METHODS: NDE was ≥ 2 ICD-9 codes in a 12-month period. Insomnia before OAU initiation was ≥1 ICD-9 code. Cox proportional hazard models stratified on insomnia assessed the relationship between initiating a 1-30, 31-90, or > 90 day period of OAU and NDE while controlling for confounders using inverse probability of treatment-weighted propensity scores (PS). RESULTS: Compared to 1-30 day OAU, 31-90 day was associated with NDE in those without (HR = 1.20; 95 percent CI: 1.12-1.28) but not with insomnia (HR = 1.06; 95 percent CI: 0.86-1.32). Results showed a stronger effect of chronic (>90) OAU in those with insomnia (HR = 1.59; 95 percent CI: 1.27-1.98) compared to those without (HR = 1.31; 95 percent CI: 1.21-1.42). However, all stratum-specific effects were not significantly different (p = 0.136). CONCLUSIONS: Although stratum-specific risks were statistically similar, there was evidence for a trend that chronic OAU is a stronger risk factor for NDE in those with versus without insomnia. Providers are encouraged to monitor sleep impairment among patients on opioid therapy, as sleep may be associated with greater risk for NDE in patients with chronic OAU.

High risk of hip dislocation following polyethylene liner exchange in total hip arthroplasty-is cup revision necessary?

PURPOSE: Polyethylene (PE) wear remains a common reason for revision surgery following total hip arthroplasty (THA). An established treatment method is isolated liner exchange in a well-fixed acetabular cup and entails a known high risk of hip dislocation after revision surgery. The purpose of this retrospective study was to determine the rate of hip dislocation after liner exchange. METHODS: Patients were included if (1) the PE liner was removable, (2) the acetabular shell was stable with acceptable orientation, (3) no osteolysis around the acetabular cup was found and (4) no dislocation of the THA occurred before revision surgery. We reviewed medical histories and performed radiological measurements using Einzel-Bild-Röntgen-Analyse (EBRA) software. EBRA measurements and statistical investigations were performed by two independent investigators. RESULTS: A total of 82 patients were included in our study. Mean follow-up was six (range: 3.6-9.9) years. In 13 (15.8%) patients THA dislocations occurred at a mean postoperative period of 20.2 (range: 1-44) weeks after revising the PE liner. This is equivalent to an absolute risk increase of 16% after revision surgery, which results in a number needed to harm of 6. This means that every sixth patient with isolated liner exchange can expect to experience dislocation due to wear. CONCLUSION: In conclusion, isolated exchange of the polyethylene liner because of wear showed a high risk of dislocation and further cup revision. Our results suggest that the threshold for revising well-fixed components in the case of liner wear should be lowered. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: Number: 20140710-1012 and Date: 2016-03-09.