An Integrated Hospital Protocol for Persons With Injection-Related Infections May Increase Medications for Opioid Use Disorder Use but Challenges Remain.

BACKGROUND: Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. METHODS: This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. RESULTS: A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in "high risk" participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. CONCLUSIONS: A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (<50%).

Extraskeletal Ewing sarcoma in a 77-year-old woman.

Extraskeletal Ewing sarcoma (EES) is a rare soft tissue tumor that is morphologically indistinguishable from Ewing sarcoma of bone. It is usually found in young people, but several cases have occurred in patients older than 50 years. The differential diagnoses include other small, blue round cell tumors (SBRCTs) and other members of the Ewing family of tumors such as the primitive neuroectodermal tumor. We present a case of EES in the left inguinal region of a 77-year-old woman. The tumor was distinguished from other SBRCTs by lack of immunoreactivity for epithelial, lymphoid, vascular, neuroendocrine, neural, histiocytic, and muscle markers. Primitive neuroectodermal tumor was excluded because of the lack of neural differentiation by histologic analysis, immunohistochemistry, and electron microscopy. Extraskeletal Ewing sarcoma was confirmed by characteristic features on histologic analysis, histochemistry, immunohistochemistry, and electron microscopy and by the presence of the t(11;22)(q24;q12) fusion transcript detected by reverse transcriptase-polymerase chain reaction. This case serves to remind the reader that EES is not a tumor that occurs exclusively in young patients.

Thrombosis of the ulnar artery: resection and microvascular vein graft.

Thrombosis of the ulnar artery occurs in an unprotected region of the hypothenar area secondary to trauma. The anatomical and pathological considerations, clinical presentations, and therapeutic management is reviewed. Two cases treated by interpositional microvascular vein grafting are presented. In the patient with severe symptoms, it is recommended that flow be restored by vein grafting when facilities and expertise are available.

Two-stage superficialis tendon reconstruction in severely damaged fingers.

In 16 fingers in 12 patients, where profundus tendon reconstruction was contraindicated due to soft tissue and distal joint changes, the superficialis tendon was reconstructed in two stages using a round silicone rod from the distal interphalangeal joint to the lumbrical level in the palm and profundus-superficialis tenorrhaphy as the first stage. The proximal end of the pedicled superficialis was used as the graft in the second stage. Fifteen fingers obtained a satisfactory result; one was a failure when the rod protruded through the skin. Two patients required a third surgical procedure: one a tenolysis at the superficialis-profundus junction, the other reattachment of the graft distally.

Diffuse pigmented villonodular tenosynovitis of the ulnar bursa--a case report.

A case report of diffuse pigmented villonodular tenosynovitis involving the entire ulnar bursa and a review of the literature are presented. There have been few reports of the diffuse form of pigmented villonodular tenosynovitis involving the hand as compared to the localized nodular form, which is a common tumor of the hand. Complete tenosynovectomy of the involved areas is recommended.

Improved results with a paramedian technique for the insertion of peritoneal dialysis catheters.

Three hundred and twenty-three permanent peritoneal dialysis catheters were inserted in 233 patients by two different methods (midline and paramedian). The paramedian technique resulted in a reduction in the incidence of dialysate leak, incisional hernia and extrusion of the cuff. These results have led to the abandonment of the midline insertion and the exclusive use of the paramedian technique for permanent dialysis catheter insertion at our institution.

Indications for operation when peritonitis occurs in patients on chronic ambulatory peritoneal dialysis.

Although peritonitis is a common complication in patients on CAPD, laparotomy is necessary in only a small proportion of instances. In order to determine the most reliable method to identify which patients require laparotomy, 78 episodes of peritonitis were studied over a 27 month period. History, physical examination and routine laboratory parameters were not useful. If multiple enteric organisms were cultured from a patient and abdominal pain persisted, the results of laparotomy always revealed significant abdominal pathologic findings. No patient required laparotomy if multiple enteric organisms were not recovered. These findings suggest that the only reliable parameter in the selection of patients for laparotomy is the presence of multiple enteric organisms in the dialysate. When abdominal pain persists in a patient with multiple enteric organisms, a laparotomy should be performed.

Genital swelling as a surgical complication of continuous ambulatory peritoneal dialysis.

Genital edema was seen as a complication of continuous ambulatory peritoneal dialysis (CAPD) in 18 patients, who accounted for 4 per cent of all patients on CAPD. In the majority of patients, the swelling developed suddenly and painlessly in the scrotum, penis or labia majora. Some of the patients noticed ultrafiltration failure. In the majority of these patients, this was a result of fluid leakage through the patent processus vaginalis. In one female patient, fluid leaked through the implantation site of the catheter. A computed tomographic scan using contrast media is a useful diagnostic tool in identifying the side of the defect in patients with generalized scrotal or penile edema. Surgical repair of the hernia and the hole in the processus vaginalis or hernia sac prevented recurrence. A trial of temporary discontinuation of CAPD or intermittent peritoneal dialysis using small volumes of dialysis fluid prevented recurrence while reinstituting CAPD in patients with normal findings from contrast studies. Intermittent peritoneal dialysis using low volumes of dialysis fluid with stepwise increase prevented recurrence while reinstituting CAPD two to three weeks after surgical repair.

A decision pathway for the staged management of foot problems in diabetes mellitus.

This review describes a decision pathway for the conservative management of foot problems in persons with diabetes mellitus. The decision pathway was developed by the Louisiana State University Health Sciences Center Diabetes Foot Program as part of the Statewide Diabetes Disease Management Initiative to standardize foot care in a medically underserved population. The pathway describes the prevention and/or management of foot problems through 5 clinical subpathways: injury prevention, warm swollen foot, ulcer, osteomyelitis, and remodeling. The pathway provides physiatrists and other rehabilitation practitioners with a framework to evaluate and manage neuropathic foot problems in a multidisciplinary setting.