Participatory evaluation of a community mobilization effort to enroll Wyandotte County, Kansas, residents through the Affordable Care Act.

Successful implementation of the Affordable Care Act (ACA) depends on the capacity of local communities to mobilize for action. Yet the literature offers few systematic investigations of what communities are doing to ensure support for enrollment. In this empirical case study, we report implementation and outcomes of Enroll Wyandotte, a community mobilization effort to facilitate enrollment through the ACA in Wyandotte County, Kansas. We describe mobilization activities during the first round of open enrollment in coverage under the ACA (October 1, 2013-March 31, 2014), including the unfolding of community and organizational changes (e.g., new enrollment sites) and services provided to assist enrollment over time. The findings show an association between implementation measures and newly created accounts under the ACA (the primary outcome).

Lower Extremity Peripheral Nerve Blocks for Patients at Risk for Acute Compartment Syndrome.

A delayed acute compartment syndrome (ACS) diagnosis often results in devastating complications; however, the sensitivity of the classic signs and symptoms is very low. All analgesic modalities have been implicated in delaying the diagnosis, but there is very little evidence linking peripheral nerve blocks (PNBs) with delays in diagnosis. In fact, there is evidence that PNBs may facilitate an early diagnosis; this may be in part due to differences in how ischemic and inflammatory pain is transmitted through unique nociceptive pathways. Collaboration is required to optimize care for patients at risk for ACS.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction.

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain.

Patients with severe burn injuries often require split-thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 and May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African-American males, but mechanism of injury varied. Over half had a neurologic (17%) or psychiatric history (34%) outside of substance use. Almost three-quarters had a history of substance use with 17% being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < .001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

Peripheral Nerve Block Complications in Children.

Regional anesthesia, and in particular peripheral nerve block (PNB) techniques, complement existing anesthetic and pain management strategies and facilitate a comprehensively safer experience for the pediatric patient. Ultimately, the use of regional anesthesia cultivates a more satisfactory experience for all involved. Complication rates are very low, making PNBs a very safe option as proliferative incorporation of ultrasound technology has led to further enhancement of regional anesthesia safety and efficacy in the pediatric population.

Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report.

BACKGROUND: A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the 'LIM' block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here. CASE: We present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries. CONCLUSIONS: The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.

The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient.

Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.

[Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation]. / Dispersão axilar de anestésico local após bloqueio interfascial torácico guiado por ultrassom - estudo radiológico e em cadáver.

BACKGROUND: Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. METHODS: After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. RESULTS: Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. CONCLUSIONS: These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block.

Forensic laboratory evidence in sexually abused children and adolescents.

OBJECTIVES: To determine if forensic laboratory evidence could be recovered from alleged sexual abuse victims more than 24 hours after the event and to determine if age or historical factors could be used to determine the need for forensic evidence collections. DESIGN: Retrospective study of hospital records matched with forensic evidence reports from the Arkansas State Crime Laboratory, Little Rock. SETTING: The emergency department at Arkansas Children's Hospital, Little Rock. PARTICIPANTS: Eighty children (aged <12 years) and adolescents (aged > or =12 years) who presented to the emergency department within 72 hours of an alleged event of sexual abuse or assault with genital contact. MAIN OUTCOME MEASURES: Cases positive for semen were correlated with age of the victim and post-event length of time to presentation to the emergency department. RESULTS: Of the 80 subjects, 16 had positive findings for semen. All 16 subjects who tested positive for semen presented to the emergency department less than 24 hours after the alleged abuse or assault event (P<.001). Of the 16 subjects who tested positive, 13 (81%) were adolescents. None of the prepubertal children had semen recovered from any body site; semen was recovered only from clothing or linen in those 3 children. CONCLUSIONS: Forensic evidence collections from body sites in child and adolescent rape patients are unlikely to yield positive results for semen (1) more than 24 hours after the event and (2) when taken from prepubertal patients. Consideration should be given to amending guidelines regarding forensic evidence collections in child and adolescent sexual abuse or assault victims.

Management of sexually abused children by non-forensic sexual abuse examiners.

Physicians who do not intend to examine children suspected of having been sexually abused still need information about the disorder and its management. A history from the caretaker and child is vital to determine the safety of the child from further abuse and the urgency of a physical evaluation for health and forensic purposes. The disclosure interview of a young child in Arkansas generally should be by an agency investigator to avoid multiple interviews, after a legally mandated report to the Child Abuse Hotline. The physical evaluation can be delayed when the conditions listed in the Table are met, and a referral to a secondary or tertiary level examiner would follow. Otherwise, immediate referral likely will be to a primary level examiner, such as in an emergency department; the child will receive an examination and tests for acute findings and possible referral to a secondary or tertiary level examiner for a more thorough examination. The child and frequently an adult family member should be referred for counseling.

Accidental scratch--or a sign of self-cutting?

Having a high index of suspicion is key to identifying adolescents who cut themselves. The approach described here can help you properly evaluate these patients and get them the help they need.

Evaluation and treatment of vertical microgenia.

OBJECTIVE: To evaluate treatment of vertical microgenia in patients with chin deformities. METHODS: Twenty-one patients were included in this retrospective review. The 3 authors performed a lengthening genioplasty with or without interpositional grafting on each patient in either an academic or a private practice setting. RESULTS: Subjective analysis suggests a substantial improvement of lower face aesthetics in all patients. The degree of subjective change depended on the type of deformity, whether there was vertical microgenia alone or in combination with a sagittal (horizontal) deficiency, and the morphologic characteristics of the labiomental sulcus. There were no significant complications. CONCLUSION: Vertical lengthening of the chin should be considered in patients with the combination of a vertically short lower facial height, deepened labiomental fold, recessive chin, and recessive and/or procumbent lower lip.

Are the benefits of a high-intensity progressive resistance training program sustained in rheumatoid arthritis patients? A 3-year followup study.

OBJECTIVE: Rheumatoid arthritis (RA) patients were reassessed for body composition and physical function mean ± SD 39 ± 6 months after commencing a randomized controlled trial involving 24 weeks of either high-intensity progressive resistance training (PRT) or low-intensity range of movement exercise (control) to determine whether the benefits of PRT (i.e., reduced fat mass [FM], increased lean mass [LM], and improved function) were retained. METHODS: Nine PRT and 9 control subjects were reassessed for body composition (dual x-ray absorptiometry) and function (knee extensor strength, chair test, arm curl test, 50-foot walk) approximately 3 years after resuming normal activity following the exercise intervention. RESULTS: At followup, PRT subjects remained significantly leaner than control subjects (P = 0.03), who conversely had accumulated considerable FM during the study period (approximately -1.0 kg versus +2.4 kg, PRT versus controls). PRT subjects also retained most of the improvement in walking speed gained from training (P = 0.03 versus controls at followup). In contrast, the PRT-induced gains in LM and strength-related function were completely lost. Data from the controls suggest that established and stable RA patients have similar rates of LM loss but elevated rates of FM accretion relative to age-matched sedentary non-RA controls. CONCLUSION: We found that long-term resumption of normal activity resulted in loss of PRT-induced improvements in LM and strength-related function, but substantial retention of the benefits in FM reduction and walking ability. The relatively long-term benefit of reduced adiposity, in particular, is likely to be clinically significant, as obesity is very prevalent among RA patients and is associated with their disability and exacerbated cardiovascular disease risk.

Genital and anal injuries requiring surgical repair in females less than 21 years of age.

STUDY OBJECTIVE: The injuries of sexually abused and assaulted girls seldom require surgical repair, and genital and anal injuries due to other causes appear to require repair uncommonly. We sought to determine the causes of genital and anorectal injuries requiring surgical repair in relation to such variables as injury sites and severity. DESIGN: Retrospective study SETTING: A large tertiary care children's hospital PARTICIPANTS: Forty-four girls less than 21 years of age who required surgical repair of genital injuries between June 1986 and April 2007 were identified. MAIN OUTCOME MEASURES: Information collected included the victims' ages, trauma mechanisms, and sites and severity of injuries. RESULTS: Injuries requiring repair of the genital and anal areas were uncommon in the 20 year period of this study. Although most injuries were due to straddle and impalement mechanisms, sexual abuse or assault was identified in 25% of the girls. The remaining 11% were victims of motor vehicle accidents. Straddle/impalement injuries involved only the external genitalia, vestibule, perineum, or posterior fourchette of 21 of the 28 girls (76%) with those injuries. The injuries of 9 of the 11 sexually abused/assaulted girls (82%) also involved the hymen, vagina, anus, or rectum. Injuries due to sexual abuse/assault and motor vehicle accidents (MVA) had average severity scores of 2.1 and 2.2, respectively, while straddle injuries had an average severity score of 1.4. (Exact Pearson chi-square P < 0.003.) The ages of the girls were unrelated to the severity of their injuries. CONCLUSIONS: Although straddle/impalement was the most commonly found mechanism of genital and anorectal injury requiring surgical repair, sexual abuse or assault was identified in 25% of the girls. Sexual abuse and assault should always be considered and assessed appropriately when such injuries are found. Consultation of a social worker or child abuse specialist may be appropriate, especially when injuries clearly not due to an MVA involve the vagina or anorectum. A suspicion of sexual abuse or assault should be reported to the legally mandated state agency in accordance with the laws of state.