ML-enhanced peroxisome capacity enables compartmentalization of multienzyme pathway.

Repurposing an organelle for specialized metabolism provides an avenue for fermentable, unicellular organisms such as Saccharomyces cerevisiae to mimic compartmentalization of metabolic pathways within different plant tissues. Peroxisomes are attractive organelles for repurposing as they are not required for yeast viability when grown on glucose and can efficiently compartmentalize heterologous enzymes to enable physical separation of cytosolic native metabolism and peroxisomal engineered metabolism. However, when not required, peroxisomes are repressed, leading to low functional capacities for heterologous proteins. Here we engineer peroxisomes with enhanced functional capacities, with the goal of compartmentalizing up to eight metabolic enzymes to enhance titers. We implement a machine learning pipeline that allows the identification of factors to overexpress, culminating in a 137% increase in peroxisome functional capacity compared to a wild-type strain. Improved pathway compartmentalization enables an 80% increase in the biosynthesis titers of the monoterpene geraniol, up to 9.5 g L-1.

Improving Pediatric Procedural Skills for EMS Clinicians: A Longitudinal Simulation-Based Curriculum with Novel, Remote, First-Person-View Video-Based Outcome Measurement.

OBJECTIVE: Emergency medical services (EMS) clinicians are expected to provide expert care to all patients, but face obstacles in maintaining skillsets required in the care of critically ill or injured children. The objectives of this study were to describe and assess the effectiveness of a pediatric-focused, simulation-based, procedural training program for EMS clinicians, delivered on-site by a pediatric simulation education team. We also describe a novel, remote, asynchronous performance outcome measurement system using first-person-view video review. METHODS: This was a prospective study of simulation-based training and procedural outcomes. The study population involved EMS clinicians at three fire-based EMS agencies stratified as urban, suburban, and rural sites. The primary outcome was performance of intraosseous catheterization (IO), bag-valve-mask ventilation (BVM), and supraglottic device placement (SGD), measured across three time points. Secondary outcomes were identification of differences across EMS agencies and participant survey responses. RESULTS: We obtained video data from 122 clinicians, totaling 561 videos, with survey response rates of 89.0-91.3%. Pre-intervention scores were high: least-square means (95% confident-intervals) 9.5 (8.9, 10.2) for IO; 9.6 (9.3, 9.9) for BVM; and 11.6 (10.9, 12.2) for SGD. There was significant improvement post-intervention: 11.5 (10.7, 12.3) for IO; 11.0 (10.7, 11.4) for BVM; and 13.6 (12.8, 14.4) for SGD. Improvement was maintained at follow-up after a median of 9.5 months: 10.5 (9.8, 11.2) for IO; 10.2 (9.9, 10.6) for BVM; and 12.4 (11.7, 13.1) for SGD. There were no statistical differences between sites. Of survey respondents, half had not cared for a critically ill or injured child in at least a year, the vast majority had not had hands-on pediatric training in over 6 months, and the majority felt that training should occur at least every 6 months. CONCLUSIONS: Our pediatric-focused, simulation-based procedural training program was associated with improvement and maintenance of high-baseline procedural performance for EMS clinicians over the study period. Findings were consistent across sites. Remote assessment was feasible. Participant surveys emphasized a desire for more pediatric-focused training and highlighted the low frequency of clinical exposure to procedures potentially needed in the care of critically ill or injured pediatric patients.

Demonstration of a compact double-reflection transmissive beam scanner operating at 1550 nm wavelength.

A compact forward-directed transmissive beam scanner operating at a wavelength of 1550 nm was constructed and characterized. The scanner consists of two wire-grid polarizers (WGPs) surrounding a 45° Faraday rotator, causing incident light to reflect once from each WGP before transmitting through the second polarizer. Scanning is achieved by tilting one of the WGPs. Measured efficiency remained above 73% over a 90° forward scan range (-45∘ to +45∘) for vertically polarized incident light. Additionally, we measured the efficiency versus beam deflection for four different incident linear polarization configurations, three of which maintained >70% efficiency for deflection angles up to -60∘.

LEAP! Rx: A randomized trial of a pragmatic approach to lifestyle medicine.

INTRODUCTION: Clinicians lack the tools to incorporate physical activity into clinical care for Alzheimer's disease prevention. We tested a 52-week exercise and health education program (Lifestyle Empowerment for Alzheimer's Prevention [LEAP! Rx]) that integrates clinician referrals and community-based fitness resources. METHODS: We randomized 219 participants to the LEAP! Rx (ie, exercise and monthly brain health education) or a standard-of-care control group and tested the effects on cardiorespiratory fitness, insulin resistance, body composition, lipids, and cognitive performance. RESULTS: Physicians were able to connect their patients to a community lifestyle intervention. The intervention group increased in cardiorespiratory fitness at 12 and 52 weeks (p = 0.005). We observed no effects on secondary measures. Participants meeting 80% of weekly goals (150 min, moderate to vigorous activity) saw greater fitness improvements than those with less than 80% (p < 0.001). DISCUSSION: These results hold promise for broad implementation of exercise interventions into larger healthcare systems and have implications for improved research recruitment strategies. TRIAL REGISTRATION: NCT No. NCT03253341. HIGHLIGHTS: Our community-based exercise program increased cardiorespiratory fitness. Our digital physician referral method increased the diversity of the participant sample. Our findings have implications for personalized dementia risk reduction strategies.

Addressing the Shortage of Academic Nurse Educators: Recommendations for Educational Institutions Based on Nominal Group Technique Research.

AIM: The purpose of this qualitative study was twofold: 1) explore factors contributing to the shortage of academic nurse educators (ANEs) and 2) identify opportunities to address these factors from the perspectives of nursing education institutions. BACKGROUND: The nurse faculty shortage is a major national concern, with inadequate recruitment and retention. Addressing the nursing faculty shortage is important to maintain a sustained nursing workforce. METHOD: Using a nominal group technique (NGT), a group of 45 diverse nurse educators from across the United States formed a virtual workgroup. RESULTS: Findings led to an action plan formulated to guide educational institutions with ways to decrease the ANE shortage through recruitment and retention. CONCLUSION: The evidence demonstrates the need for educational institutions to concentrate efforts on recruiting and retaining ANEs to combat the nursing shortage. The analysis offers recommendations to institutions to increase the number of qualified ANEs.

Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors.

BACKGROUND: Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations. PATIENTS AND METHODS: In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed. RESULTS: Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05). CONCLUSIONS: We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

Peroxisome compartmentalization of a toxic enzyme improves alkaloid production.

Eukaryotic cells compartmentalize metabolic pathways in organelles to achieve optimal reaction conditions and avoid crosstalk with cytosolic factors. We found that cytosolic expression of norcoclaurine synthase (NCS), the enzyme that catalyzes the first committed reaction in benzylisoquinoline alkaloid biosynthesis, is toxic in Saccharomyces cerevisiae and, consequently, restricts (S)-reticuline production. We developed a compartmentalization strategy that alleviates NCS toxicity while promoting increased (S)-reticuline titer. This strategy is achieved through efficient targeting of toxic NCS to the peroxisome while, crucially, taking advantage of the free flow of metabolite substrates and products across the peroxisome membrane. We demonstrate that expression of engineered transcription factors can mimic the oleate response for larger peroxisomes, further increasing benzylisoquinoline alkaloid titer without the requirement for peroxisome induction with fatty acids. This work specifically addresses the challenges associated with toxic NCS expression and, more broadly, highlights the potential for engineering organelles with desired characteristics for metabolic engineering.

Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex.

BACKGROUND: Lisfranc Ligamentous Complex (LLC) injuries are commonly misdiagnosed due to their unreliable projection on plain films. Weightbearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish widely referenced baseline anatomic positions. METHODS: A retrospective chart review was conducted of patients who had undergone weightbearing CT of the bilateral lower extremities with one-hundred and twelve being included (56 patients). Measurements of the Lisfranc joint were collected by two independent reviewers. Uninjured symmetric anatomy was used to describe a baseline for normal anatomic variation and to evaluate for sex-based or age-related differences. These measurements were then compared against the injured side. RESULTS: In patients without Lisfranc injury, the 1st metatarsal base to 2nd metatarsal base distance (Base M1-M2) was 2.7 + /- 0.7 mm; 2nd metatarsal base to medial cuneiform (M2-C1) was 3.7 + /- 0.7 mm; intercuneiform distance was 1.2 + /- 0.3 mm; and sagittal descent 12.2 + /- 5.4 mm. Patients with injury to LLC had a larger M1-M2 base distance (Δ = 0.5903, p < 0.0001) and M2-C1 interval (Δ = 1.8008, p < 0.0001) compared to uninjured side. Males had significantly higher M2-C1 (p = 0.0031), intercuneiform distance (p = 0.0039), and sagittal descent (p = 0.0008) compared to female patients. No significant differences were found between left versus right side in any of the measurements. Intercuneiform distance (p = 0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p = 0.0066). CONCLUSION: Weightbearing CT has high utility in identification of Lisfranc injuries particularly when comparing injured and uninjured sides, which may be its greatest utility in defining injuries. This is evident in the excellent diagnostic ability of the M2-C1 measurement. By defining baseline anatomic measurements for Lisfranc complex parameters in our patient population, we provide normal parameters for comparison when evaluating potential subtle injuries. LEVEL OF EVIDENCE: III.

Males and Females Exhibit Comparable Outcomes Following Treatment of Osteochondritis Dissecans Lesions of the Knee: A Systematic Review.

PURPOSE: The purpose of this study was to evaluate the impact of patient sex on outcomes after treatment of osteochondritis dissecans (OCD) lesions of the knee through a systematic review of current evidence. METHODS: This review was conducted according to the PRISMA guidelines using the PubMed, PubMed Central, Embase, Ovid Medline, Cochrane Libraries, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Relevant outcomes included functional (e.g., International Knee Documentation Committee and Subjective Knee Evaluation, Lysholm Knee Score) and clinical outcomes (e.g., symptom/pain resolution, reoperation rates) for males and females after operative or nonoperative treatment of knee OCD lesions. RESULTS: Ten articles with a total of 691 (73%) males and 260 (27%) females were included. Mean age ranged from 11.3 ± 2.1 years to 34.5 ± 10.3 years, and follow-up ranged from 6 months to 16.3 years. In four studies reporting functional outcomes, no significant differences were found between males and females in any metric assessed (all P > .05). Seven studies reported clinical outcomes after treatment of knee OCD lesions. One study determined males were more likely to have a successful nonoperative outcome than females (OR: 1.85, 95% CI: 1.00-3.40). Another study found males had a lower risk of developing symptomatic knee pain following operative or nonoperative treatment at a mean 14-year follow-up (HR: 0.24; 95% CI: 0.07-0.81). The remaining 5 studies reported statistically comparable clinical outcomes between males and females (all P > .05). CONCLUSION: The present systematic review found mostly comparable clinical and functional outcomes between males and females following treatment of knee OCD lesions. Despite sex-related differences in the prevalence of these lesions and limited evidence of differences in clinical outcomes, these data suggest that sex does not independently predict outcomes after treatment. LEVEL OF EVIDENCE: III, systematic review of Level II and III studies.

Rapid Identification of Disulfide Bonds and Cysteine-Related Variants in an IgG1 Knob-into-Hole Bispecific Antibody Enhanced by Machine Learning.

Bispecific antibodies are regarded as the next generation of therapeutic modalities as they can simultaneously bind multiple targets, increasing the efficacy of treatments for several diseases and opening up previously unattainable treatment designs. Linking two half antibodies to form the knob-into-hole bispecific antibody requires an additional in vitro assembly step, starting with reduction of the antibodies and then reoxidization. Analysis of the disulfide bonds (DSBs) is vital to ensuring the correct assembly, stability, and higher-order structures of these important biomolecules because incorrect disulfide bond formation and/or presence of cysteine-related post-translational modifications can cause a loss of biological activity or even elicit an immune response from the host. Despite advancements in analytical methods, characterization of cysteine forms remains technically challenging and time-consuming. Herein, we report the development of an improved nonreduced peptide map method coupled with machine learning to enable rapid identification of disulfide bonds and cysteine-related variants in an IgG1 knob-into-hole bispecific antibody. The enhanced method offers a fast, consistent, and accurate workflow in mapping-out expected disulfide bonds in both half antibodies and bispecific antibodies and identifying cysteine-related modifications. Comparisons between two versions of the bispecific antibody molecule and analysis of stressed samples were also accomplished, indicating this method can be utilized to identify alterations originating from bioprocess changes and to determine the impact of assembly and postassembly stress conditions to product quality.

Microfluidic bubbler facilitates near complete mass transfer for sustainable multiphase and microbial processing.

A microfluidic device (channels <70 µm) was utilized to create micro-scale bubbles to significantly increase mass transfer efficiency at low flow rates. The convergence of one gas and two liquid channels at a Y-junction generates bubbles via cyclic changes in pressure. At low flow rates, the bubbles had an average diameter of 110 µm, corresponding to a volumetric mass transfer KL a of 1.43 h(-1) . Values of KL a normalized per flow rate showed that the microbubbler had a 100-fold increased transfer efficiency compared to four other commonly used bubblers. The calculated percentage of oxygen transferred was approximately 90%, which was consistent with a separate off-gas analysis. The improved mass transfer was also tested in an algae bioreactor in which the microbubbler absorbed approximately 90% of the CO2 feed compared to 2% in the culture with an alternative needle bubbling method. The microbubbler yielded a cell density 82% of the cell density for the alternative needle tip with an 800-fold lower flow rate (0.5 mL/min versus 400 mL/min) and a 700-fold higher ratio of biomass to fed carbon dioxide. The application of microfluidics may transform interfacial processing in order to increase mass transfer efficiencies, minimize gas feeding, and provide for more sustainable multiphase processes. Biotechnol. Bioeng. 2016;113: 1924-1933. © 2016 Wiley Periodicals, Inc.

Evaluation of learning curve with Indocyanine Green (IcG) versus blue dye for sentinel lymph node biopsy in breast cancer.

BACKGROUND: Indocyanine green (IcG) is an alternative to isosulfan blue (IB) for sentinel lymph node (SLN) mapping in breast cancer (BC). IcG carries improved cost and safety, but oncologic data upon implementation in practice is limited. We evaluated the learning curve defined as oncologic yield and operative (OR) time for IcG in SLN mapping in BC. METHODS: Retrospective review of patients >18 years with cTis-2 cN0 BC undergoing surgery first with SLN biopsy using IB or IcG. Analysis compared IB versus IcG across three time cohorts. RESULTS: Of 278 patients, 77 received IB and 201 received IcG. OR time was longer for IcG (p â€‹= â€‹0.022). There was no difference in oncologic yield between groups (p â€‹= â€‹0.35, p â€‹= â€‹0.61). CONCLUSIONS: Surgeons may be able to safely transition from IB to IcG for patients with early-stage breast cancer undergoing surgery first. Individuals should track their own data to confirm safety of the technique.

Emergency Action Planning in United States High Schools.

BACKGROUND: Rates of emergency action plan (EAP) implementation and compliance with EAP guidelines vary in United States secondary schools. There are limited data on emergency preparedness in schools without athletic trainers (ATs). HYPOTHESIS: Rural and high poverty schools have poor emergency preparedness for high school athletic events due to financial barriers and lack of ATs. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 5. METHODS: A web-based questionnaire was emailed by each State High School Athletics Association to ATs, athletic directors, and coaches of recipient schools to assess emergency preparedness. RESULTS: A total of 686 responses were received (response rate ~3.5%). Schools with an AT on staff were more likely to have an EAP (P < 0.01). Schools with a higher enrollment were more likely to have an EAP (P < 0.01), an AT on staff (P < 0.01), require additional training for coaches (P < 0.01), and have an automated external defibrillator (AED) onsite for all events (P < 0.01). Urban (odds ratio [OR], 3.514; 95% CI [2.242, 5.507]; P < 0.01) and suburban (OR, 4.950; 95% CI [3.287, 7.454]; P < 0.01) districts were more likely than rural districts to have an AT on staff. High poverty districts were less likely to have an AED (OR, 0.660; 95% CI [0.452, 0.964]; P = 0.03) or EAP (OR, 0.511; 95% CI [0.306, 0.853]; P < 0.01) at athletic venues. CONCLUSION: Lower enrollment, high poverty, and rural schools are less prepared for athletic emergencies than their higher enrollment, low poverty, and suburban counterparts as these schools are generally less likely to have an AT on staff, AEDs, and EAPs and less likely to provide additional training to coaches and other staff. CLINICAL RELEVANCE: This study assesses athletic emergency preparedness-a critical component of ensuring athlete safety and recovery after injury.

Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Interactive multidisciplinary pilot workshop to improve medical student perception of and interest in breast surgical oncology.

BACKGROUND: Exposure to breast surgical oncology (BSO) and the multidisciplinary management of patients with breast cancer is limited in medical school. The purpose of this study was to assess changes in student perceptions of BSO as a career following an interactive multidisciplinary workshop. METHODS: Pre-clinical medical students participated in a multidisciplinary, hands-on workshop, composed of breast radiology (BR), breast surgical oncology (BSO) and breast plastic reconstructive surgery (B-PRS). BR presented students screening and diagnostic breast imaging followed by hands-on ultrasound-guided biopsy on phantom simulators. BSO demonstrated lumpectomy, mastectomy, sentinel lymph node biopsy, and axillary lymph node dissections while B-PRS demonstrated oncoplastic techniques and autologous flap reconstruction with cadavers. Pre-and post-workshop surveys assessed student opinions on surgery and BSO. Results were compared using Wilcoxon Signed Rank, Wilcoxon Rank Sum, and Fisher's Exact. RESULTS: The workshop was attended by twenty-four students. There was a statistically significant increase in interest in BSO from 52% to 86% after the workshop (p = 0.003). The event improved understanding of the work and lifestyle in BSO for 79% (19/24). All students (100%) expressed interest to further explore BSO. The most common attractors to a career in BSO were impacts on patients' lives (N = 23), intellectual stimulation (N = 22), and earnings (N = 20). The most reported deterrents were lack of personal time (N = 18) and stress (N = 15). CONCLUSION: An interactive, anatomically based exposure to multidisciplinary breast cancer surgery improves medical student perception and interest in BSO. Medical schools should consider incorporating similar events to foster interest in BSO and other surgical subspecialties.

Assessing the Risk of Postoperative Complications for Proximal Humeral Fractures Treated by Open Reduction and Internal Fixation in Patients With Diabetes and Chronic Kidney Disease.

BACKGROUND: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) has markedly risen over the past three decades. Patients with DM and CKD are at increased risk of infection, immune dysfunction, as well as bone and mineral disorders. Although we know that patients with DM and CKD have these risks, we do not know how these translate to proximal humeral fracture (PHF) healing. We sought to analyze whether these established comorbidities had increased rates of complications after open reduction and internal fixation (ORIF) for PHF treatment. METHODS: Using a national insurance database, 72,365 patients with PHF managed with ORIF were identified using records from 2010 to 2022. Patients were initially split into those with DM and those without and were further stratified by the presence or absence of CKD. For our comparison baseline cohort, patients were not diagnosed with either DM or CKD. Post-ORIF complication rates were assessed looking specifically at nonunion, postoperative infection, and all-cause revision surgery. A logistic regression statistical analysis was also conducted. RESULTS: Of the 72,365 patients with PHF treated by ORIF, 41,047 were non-DM without CKD (comparison); 17,025 had DM alone (no CKD); 11,729 had DM and CKD; and 2564 had CKD alone (non-DM). Multivariate analysis indicated that patients with DM and/or CKD were at increased risk of developing nonunion (odds ratio [OR] = 1.37, 1.48, 1.23) and all-cause revision surgery (OR = 1.21, 1.11, 1.18) after ORIF for PHF compared with our comparison cohort. In addition, all patients with DM alone (non-CKD) and DM with CKD had an increased risk of postoperative infection (OR = 1.39, 1.26). CONCLUSION: The management of PHF is a controversial topic, particularly regarding the degree of intervention and optimal treatment choice. Regardless, using a pragmatic design and reviewing a national insurance database, this study provides information for patients in high-risk populations, specifically patients with DM and CKD, and may prove beneficial when selecting a patient-specific treatment plan. Additional studies are needed to assess varying stages of both DM and CKD in patients who sustain PHF treated by ORIF along with postoperative strategies to minimize complications.

Patient Polypharmacy use Following a Multi-Disciplinary Dementia Care Program in a Memory Clinic: A Retrospective Cohort Study.

Introduction: Dementia increases the risk of polypharmacy. Timely detection and optimal care can stabilize or delay the progression of dementia symptoms, which may in turn reduce polypharmacy. We aimed to evaluate the change in polypharmacy use among memory clinic patients living with dementia who participated in a dementia care program compared to those who did not. We hypothesized that patients in the dementia care program would reduce their use of polypharmacy compared to those who were not in standard care. Methods: We retrospectively analyzed data extracted from electronic medical records from a university memory clinic. Data from a total of 381 patients were included in the study: 107 in the program and 274 matched patients in standard care. We used adjusted odds ratios to assess the association between enrollment in the program and polypharmacy use at follow-up (five or more concurrent medications), controlling for baseline polypharmacy use and stratified polypharmacy use by prescription and over-the-counter (OTC). Results: The two groups did not differ in the use of five or more overall and prescription medications at follow-up, controlling for the use of five or more of the respective medications at baseline and covariates. Being in the program was associated with a three-fold lower odds of using five or more OTC medications at follow-up (adjusted odds ratio = 0.30; p <0.001; 95% Confidence interval = 0.15-0.58) after controlling for using five or more OTC medications at baseline and covariates. Conclusions: Dementia care may reduce polypharmacy of OTC medications, potentially reducing risky drug-drug interactions. More research is needed to infer causality and understand how to reduce prescription medication polypharmacy.

Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.