Residents Perceive Limited Education on Family Planning and Contraception for Patients with Severe and Persistent Mental Illness.

OBJECTIVE: The primary goal of this study was to assess perceived adequacy of training by residents from multiple specialties on contraceptive prescribing and family planning for patients with severe and persistent mental illness (SPMI). Secondary goals included the following: (1) explore resident knowledge, attitudes, and behavior towards patients with SPMI and (2) identify barriers to meeting the reproductive health needs of patients with SPMI. METHODS: The target population was 44,237 residents from four medical specialties. Participants were from a stratified, self-selected sample. Program coordinators were asked to forward a survey link to residents. Consenting residents were provided access to a questionnaire via a secure, web-based application (REDCap). The survey assessed resident education on the reproductive health needs of patients with SPMI and included demographics (age, gender, year of residency, and specialty), perceived adequacy of training, knowledge, and attitudes, and barriers regarding contraception and family planning. Responses were summarized with frequency and compared by medical specialty. RESULTS: A total of 768 residents consented: 49% female, 20% male, and 31% did not indicate their gender; 19% were first year residents, 21% second year residents, 21% third year residents, 8% fourth year residents, and 30% did not indicate their year of training. By specialty, 30.6% of residents were from family medicine programs (n = 235), 10.8% were from internal medicine programs (n = 83), 18.1% were from OBGYN programs (n = 139), and 10.4% were from psychiatry programs (n = 80); 231 (30.1%) did not indicate specialty. Regarding training, 60% of residents disagreed or strongly disagreed that they had proper training on prescribing contraceptives for patients with SPMI (363 of 599). Sixty two percent of residents disagreed or strongly disagreed that they had proper training about family planning for patients with SPMI (368/599). Over 83% of residents surveyed (405/486) would prescribe contraception for patients with SPMI if they had adequate training. CONCLUSIONS: Results indicate the need for curricular change on the reproductive health needs of patients with SPMI.

Short-term Functional Outcomes and Complications of Custom Patellofemoral Arthroplasty.

Background: Patellofemoral arthroplasty (PFA) is a treatment option for isolated patellofemoral arthritis. Custom PFA is an innovative procedure utilizing patient-specific instrumentation. The purpose of this study is to evaluate short-term functional outcomes and complications of the custom PFA in treatment of isolated patellofemoral arthritis. Methods: A retrospective study was conducted to analyze patients who received a PFA operation from a single surgeon. Inclusion criteria were surgical patients from 2012 to 2018 who underwent PFA using a custom prosthesis implant. Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) and Lower Extremity Functional Scale (LEFS) were collected before and after surgery. Results: A total of 79 patients (94 knees) participated in the study; 55 (69.6%) were women. The median age was 57 at the time of index arthroplasty; 15 patients (30 knees) were bilateral. Follow-up rate was 94%. Median follow-up duration was 3.6 years (2-8.9). Overall prefunctional and postfunctional scores differed significantly for both KOOS, JR and LEFS. Postoperative scores increased for KOOS, JR by 27.5 points, and for LEFS, they increased 26.0 points; P < .001 for both. Complications included 6 reoperations (6.7%) related to PFA: 4 conversions (4.4%) to total knee arthroplasty at a median of 2.5 (1.5-3) years after the index procedure, one vastus medialis oblique advancement (1.1%) secondary to patellar maltracking, and one manipulation under anesthesia (1.1%). Conclusions: Custom PFA in patients with isolated patellofemoral arthritis showed good short-term functional outcomes and low revision rates with very few complications.

Electronic Monitoring of Mom's Schedule (eMOMSTM): A Qualitative Study of Experiences in a Lifestyle Change Program with Lactation Support.

PURPOSE: To elicit feedback from participants who completed the eMOMSTM study, a feasibility randomized controlled trial (NCT04021602), on their perceptions of program strengths and weaknesses. STUDY DESIGN: Qualitative - Semi-structured, telephone interview guide using open-ended questions. SETTING: Rural Great Plains state, United States. PARTICIPANTS: Of 26 individuals who completed the eMOMSTM study, 24 consented to an interview. METHOD: Interviews were completed between October 2020 and May 2021. Audio-recordings were transcribed verbatim and organized in Microsoft 365. Data were analyzed using an exploratory, inductive thematic analysis. RESULTS: Participants' mean age was 27.5 (± 5.4) years and mean pre-pregnancy BMI was 29.5 kg/m2 (± 2.7). The majority (71%) were non-Hispanic White and 54% had a high school education/some college. Based on specific areas of inquiry, the following themes emerged: convenience of online program access using Facebook, importance of health coach's support and online interaction, positivity toward improving one's health, increased consciousness of health behaviors, diverse lactation educational needs, importance of educational materials on depression, and grief over the loss of birth expectations during COVID-19. CONCLUSION: Findings suggest participants' perceived value of a lifestyle change program coupled with lactation education and support delivered using social media. Findings inform future studies to further adapt lifestyle change programs.

A Scoping Review to Assess Risk of Fracture Associated with Anxiolytic Medications.

Introduction: Recent research has focused on evaluating the impact of pharmalogical sources on fracture risk. The purpose of this study was to review the literature on anxiolytic medications that may be associated with an increased risk of fracture. Methods: A search was conducted in MEDLINE and Embase databases to identify primary clinical studies of patients who sustained a fracture while prescribed anxiolytic medications and were published prior to July 2021. Anxiolytics defined by ATC Class N05B, beta blockers, and zolpidem were included. The search terms consisted of variations of the following: ("Psychotropic Drugs" or MeSH terms) AND ("Fracture" or MeSH terms). Results: Of 3,213 studies, 13 (0.4%) met inclusion criteria and were evaluated. Fractures associated with benzodiazepine were reported in 12 of 13 studies; the highest risk occurred in patients aged 60 years and older (RR=2.29, 95% CI (1.48-4.40)). The ATC Class N05B showed an increased fracture risk for those ≤ 55 years of age that differed by sex: for men (RR=5.42, 95% CI(4.86-6.05)) and for women (RR=3.33, 95% CI (3.03-3.66)). Zolpidem also showed an increase fracture risk (RR=2.29, 95% CI(1.48-3.56)), but only during the first four weeks of treatment. A relative risk of 0.77, 95% CI(0.72-0.83) was observed for beta blockers. Conclusions: Fractures are a mainstay of traumatic injuries and are accompanied by economical, physiological, and psychological hardship. With proper assessment and prophylactic measures, fracture risk can be reduced dramatically. Anxiolytic medications have been described widely to increase fracture risk, such as benzodiazepines in 60+ year old patients, and ATC Class N05B anxiolytics increased fracture risk in 55+ year old men and in 55+ year old women. Yet, some studies showed that at low doses, nitrazepam lowered fracture risk. Other anxiolytic medications, such as zolpidem and beta blockers, also showed a decrease in fracture risk. Ultimately, this scoping review helped to illuminate the inconsistency of anxiolytic fracture risk assessment while simultaneously illustrating the necessary steps to guide future research.

Electronic Monitoring Of Mom's Schedule (eMOMSTM): Recruitment of pregnant populations with elevated BMI in a feasibility randomized controlled trial.

Underrepresentation of pregnant populations in randomized controlled trials of lifestyle change interventions is concerning due to high attrition and providers' limited clinical time. The purpose of this evaluative study was to assess intervention uptake of pregnant individuals enrolled in a three-arm feasibility randomized controlled trial, electronic Monitoring Of Mom's Schedule (eMOMSTM), examining lifestyle changes and lactation support alone, and in combination. Measures included: (1) participation and completion rates, and characteristics of intervention completers versus other eligible participants; and (2) provider experiences with screening and enrolling pregnant participants. Pregnant people with a pre-pregnancy body mass index ≥ 25 and < 35 kg/m2 were enrolled into the eMOMSTM trial between September 2019 - December 2020. Of the 44 consented participants, 35 were randomized, at a participation rate of 35%, and 26 completed the intervention, resulting in a completion rate of 74%. Intervention completers were slightly older and entered the study earlier in pregnancy compared to non-completers. Completers were more likely to be first-time mothers, resided in urban areas, had higher educational attainment, and were slightly more racially and ethnically diverse. A majority of providers reported willingness to participate, believed the study aligned with their organization's mission, and were satisfied with using iPads for screening. Lessons learned to guide recruitment success include use of: (1) designated research staff in combination with physician support; and (2) user-friendly technology to help mitigate time burden on physicians and their staff. Future work should focus on successful strategies to recruit/retain pregnant populations in clinical trials.

Causes of Anemia in Patients Seen in a Rural Community Hematology Clinic.

Introduction: Anemia is a common medical disorder seen in consultation by hematologists. This study was performed to determine the incidence of the etiologies causing anemia in patients referred to the hematologists at Tammy Walker Cancer Center (TWCC) in the rural Kansas community of Salina. An additional goal of the study was to compare the frequencies of different etiologies for anemia in this cohort of patients with those previously reported by four academic medical centers. Methods: A retrospective review of the medical records of 152 patients seen at TWCC between August 2015 and May 2019 was performed. The patient's history and physical exam, complete blood count, and various additional hematologic studies ordered at the discretion of the TWCC hematologist were used to determine the etiology of each patient's anemia. Results: The most common causes of anemia found in the chart review were iron deficiency (48.7%), hematologic malignancy (14.5%), chronic inflammation (13.8%), renal insufficiency (11.2%), and unexplained anemia (9.9%). While the incidences of anemia due to hematologic malignancy, chronic inflammation, and renal insufficiency were like that reported previously by four academic medical centers, significantly more iron deficiency and less unexplained anemia were found in the patients referred to TWCC. Conclusions: The causes of anemia in patients seen at TWCC were similar to those reported by academic medical centers; however, the incidences were different. The differences in findings may reflect dissimilarities in the demographics of referral populations, the duration, and extent of the evaluation at TWCC, or referral patterns.

Understanding the relationship between personality pathology and attachment style in the context of the DSM-5 Alternative Model of Personality Disorders.

This study utilizes the two different criteria of the DSM-5 Alternative Model of Personality Disorder Assessment to evaluate the relationship between attachment style and personality pathology. One-hundred forty patients from a combined sample of psychiatric and internal medicine clinics were given a survey composed of the DSM-5 Levels of Personality Functioning Questionnaire (DLOPFQ), the Personality Inventory for DSM-5-Brief Form (PID-5-BF), and the Relationship Questionnaire (RQ). Analysis of variance indicated that attachment styles were differentiated across all four the DLOPFQ scales and the Detachment trait domain. Elastic net regression modeling with bootstrap was used to assess the strength of the level of personality functioning dimensions and trait domains in the prediction of attachment style, both independently and interactively while accounting for multicollinearity. This study offers readers insight to a novel statistical approach to model building that addresses two issues among psychiatric data: high correlation and small sample size.

Primary Repair, Reconstruction, and Suture Tape Augmentation All Provide Excellent Outcomes for Lateral Ligament Instability: A Systematic Review.

Purpose: To analyze the literature to compare outcomes and complications following primary lateral ankle ligament repair compared with lateral ankle ligament reconstruction and the suture tape augmentation in patients with lateral ankle instability. Methods: Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria, a systematic literature review using the PubMed/Ovid Medline database was performed (October 11, 1947, to October 1, 2019). Clinical trials that included all the following criteria were considered eligible; published in the English language; patients undergoing primary lateral ankle repair or reconstruction with/without autograft or allograft (anterior talofibular ligament, anterior talofibular ligament + calcaneofibular ligament) or suture tape augmentation; a follow-up at least 1 year; reported least 1 of the measured outcomes (The American Orthopaedic Foot Ankle Score, Karlsson Score, return to sport [RTS], complications, skin wound complications, reoperation). Surgical techniques were evaluated, and studies were subdivided by the following categories: primary repair (PR), reconstruction with graft (GR), and suture tape augmentation (STA). Complications, radiographic outcomes, functional outcome scores, and RTS were analyzed. Results: A total of 41 of 1,991 studies met the criteria for final analysis. This included 1,920 patients who underwent surgical intervention for chronic lateral instability with at least a 1-year follow-up. There were 350 patients who had GR, 1,486 who underwent the PR, and 84 who had STA. GR group appeared to have the lowest rate of complications: GR 3.1% (11 of 350), PR 4.2% (63 of 1486), and STA 10.7% (9 of 84). Postoperative American Orthopaedic Foot Ankle Score ranged from 89.0 to 95.1 for GR and 90.0 to 98.8 for PR. Postoperative Karlsson scores ranged from 80.9 to 94.4 for GR and from 89.2 to 94.1 for PR. Anterior drawer postoperative scores ranged from 1.4 to 30.3 mm for GR, 2.7 to 8.6 mm for PR, and 4.1 to 4.2 mm for STA. Postoperative talar tilt ranged from 2.4 to 7.3° for GR, 1.9 to 6.0° for PR, and 3.6 to 4.5° for STA. RTS ranged from 9.5 to 20.4 weeks for the PR group; one study reported a RTS of 10.6 weeks for STA. Conclusions: Excellent outcomes were noted across all intervention groups. Current literature may suggest there is no difference in functional outcomes between patients treated with PR versus GR. However, there may be a potential improvement in functional outcomes with PR versus STA. Level of Evidence: Level IV, systematic review of Level I to Level IV studies.

Workplace Stress and Productivity: A Cross-Sectional Study.

INTRODUCTION: The primary purpose of this study was to evaluate the association between workplace stress and productivity among employees from worksites participating in a WorkWell KS Well-Being workshop and assess any differences by sex and race. METHODS: A multi-site, cross-sectional study was conducted to survey employees across four worksites participating in a WorkWell KS Well Being workshop to assess levels of stress and productivity. Stress was measured by the Perceived Stress Scale (PSS) and productivity was measured by the Health and Work Questionnaire (HWQ). Pearson correlations were conducted to measure the association between stress and productivity scores. T-tests evaluated differences in scores by sex and race. RESULTS: Of the 186 participants who completed the survey, most reported being white (94%), female (85%), married (80%), and having a college degree (74%). A significant inverse relationship was observed between the scores for PSS and HWQ, r = -0.35, p < 0.001; as stress increased, productivity appeared to decrease. Another notable inverse relationship was PSS with Work Satisfaction subscale, r =-0.61, p < 0.001. One difference was observed by sex; males scored significantly higher on the HWQ Supervisor Relations subscale compared with females, 8.4 (SD 2.1) vs. 6.9 (SD 2.7), respectively, p = 0.005. CONCLUSIONS: Scores from PSS and the HWQ appeared to be inversely correlated; higher stress scores were associated significantly with lower productivity scores. This negative association was observed for all HWQ subscales, but was especially strong for work satisfaction. This study also suggested that males may have better supervisor relations compared with females, although no differences between sexes were observed by perceived levels of stress.

Analysis of Patient Handoff Between Providers at a Tertiary Urban Medical Center.

INTRODUCTION: Few studies have quantified the total number of attending and consulting physicians involved in inpatients' care, and no other research quantifies the total number of all providers participating in inpatients' care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients' care for all admitted patients at a tertiary urban medical center. METHODS: The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 1, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation. RESULTS: The sample included information from 200 patient charts. Patients' ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients' stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care. CONCLUSIONS: Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care.

Early Versus Delayed Mobilization Post-Operative Protocols for Primary Lateral Ankle Ligament Reconstruction: A Systematic Review and Meta-Analysis.

INTRODUCTION: Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization, which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review was to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature. METHODS: Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947 - 1/28/2020). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical, and non-English language were excluded. Protocols were reviewed and divided into two categories: early mobilization (within three weeks of surgery) and delayed mobilization (after three weeks of surgery). Functional outcome scores (American Orthopedic Foot and Ankle Society Score (AOFAS), Karlsson scores), radiographic measurements (anterior drawer, talar tilt), and complications were evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models. RESULTS: After our search, twelve out of 1,574 studies met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group (28.0 (5.5) vs. 26.3 (0.0), respectively; p < 0.001), although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high. CONCLUSIONS: While there are some conflicting results, the findings indicated the timing of post-operative mobilization made no difference in functional outcomes or post-operative stability for patients undergoing lateral ankle ligament reconstruction. Because heterogeneity was high, future studies are needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.

Twenty percent of a representative sample of patients taking bupropion have abnormal, asymptomatic electroencephalographic findings.

The risk of dose-dependent seizures is a safety issue with bupropion hydrochloride. To evaluate the presence of specific electroencephalographic (EEG) waveforms, 210 adult subjects taking stable doses of bupropion hydrochloride were recruited to undergo 2 EEGs in a prospective, single-center cohort study. The occurrence of spike waves, sharp waves, and focal slowing was recorded and assessed with a continuation ratio logit model for polytomous responses. This model showed that there was a relationship between sex and the incidence of these waveforms, such that the odds of female subjects having sharp waves was increased by a factor of 2.53 (P = 0.05) when compared with male subjects and controlled for both age and dose. Similarly, female subjects were 2.45 (P = 0.09) times more likely than males to have focal slowing on EEG. Overall, 19.8% (39/197) of this representative population was found to have abnormal, asymptomatic EEG findings. The presence of these waveforms in individuals taking a medication known to lower the seizure threshold may be a risk factor for developing seizures.

A Survey of County Health Departments of Kansas Regarding COVID-19.

INTRODUCTION: SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2) causing COVID-19 (Coronavirus Disease 2019) initially was identified in China in December 2019. It has resulted in a pandemic with increasing spread of the virus in the U.S. The county health departments around U.S. are spearheading the response to contain the spread of this virus. METHODS: This project was a survey of county health departments in the state of Kansas with data collection period from April 15 to April 24, 2020. This study evaluated the staffing, resources, and funding of these health departments and how it was affecting the efforts to contain COVID-19. Descriptive statistics were used to summarize the responses. RESULTS: A total of 75% of the county health departments in Kansas responded to the survey. In 89% of locations, the staffing had not increased. Most health departments had an average of five people and the four largest ones had 30 to 98 staff working on COVID-19. Most locations used the Kansas Department of Health and Environment criteria for testing and used a combination of state or private laboratories. The results of the tests were available three days or longer in 62% and after five days in 14% of sites. All locations were active in contact tracing, but most had one to three people for this purpose and in 90% the contact tracing interview was via phone calls. There was no change in funding in 21% and decreased funding in 8.5% of health departments. Most locations had an average of five nasopharyngeal swabs on the day of the survey. The most common needs expressed were help to increase testing capability, more public education, more personal protective equipment, increased personnel, and assistance with contract tracing. CONCLUSION: There is an urgent need in Kansas to increase support to county health departments for testing capability, personal protective equipment, increased number of staff, increased help with contact tracing, and especially increase support for public education.

Seizures in Pre-term Infants Less than 29 Weeks: Incidence, Etiology, and Response to Treatment.

INTRODUCTION: Seizures are neurological emergencies with short-and long-term adverse effects in pre-term infants. They may present with or without abnormal movements (clinical versus subclinical). Thus, the true incidence of seizures may be under-reported. Current research indicates that most seizures occur in the first few days of life, are associated with intraventricular hemorrhage (IVH), and show low response to anticonvulsant drugs. The purpose of this study was to evaluate incidence, etiology, clinical antecedents, mortality, and response to treatment of seizures in extremely pre-term infants. METHODS: This is a retrospective cohort study of pre-term infants < 29 weeks gestation from January 2011 to December 2013. Presence or absence of seizure was the outcome. Data extraction included demographics, medications, co-morbidities, mortality, and details of seizures. A multivariable prediction model was developed to evaluate risk for seizures. RESULTS: Analysis included 269 pre-term infants. Incidence of EEG-confirmed seizures was 40% (108/269); 49% were clinical and 51% were subclinical. Seizures occurred in 72% of infants ≤ 24 weeks, 57% of those 25-26 weeks, and 23% of those 27-28 weeks. Most seizures (85%) occurred after day eight of life. Mortality was 14% in those with seizures versus 5% in those without (p = 0.019). The model showed seizures were associated significantly with gestational age and medications, while controlling for sex, APGAR score, and co-morbidities, including IVH. At discharge, anticonvulsants were continued in 66% (72/108) of infants with seizures. CONCLUSION: The incidence of seizures was highest in infants born most premature. Contrary to previous research, nearly two-thirds of pre-term infants with seizures did not have IVH or cystic periventricular leukomalacia; apnea of prematurity was a common presentation of subclinical seizures; and the majority of treated infants responded to Phenobarbital. These findings need be explored in future research.

Urine Screening for Opioid and Illicit Drugs in the Total Joint Arthroplasty Population.

INTRODUCTION: Recent studies have shown an increase in post-operative orthopaedic complications associated with pre-operative opioid use. It is, therefore, important to know if patients use opioids before scheduled surgery. The purpose of this study was to determine if urine drug screening (UDS) is an effective screening tool for detecting opioid and illicit drug use prior to joint arthroplasty (JA) procedures. METHODS: This retrospective chart review was performed with IRB approval on 166 out of 172 consecutive patients in a community-based practice. All the patients had a pre-operative UDS prior to primary or revision JA by a fellowship trained orthopaedic surgeon between March 2016 and April 2017. Patient demographics documented opioid and illicit drug use, co-morbid diagnosis, and UDS results were collected from clinical charts. Statistical analysis was conducted using Pearson Chi-square, Fisher's exact, McNemar test, and t-tests with IBM SPSS Statistics, ver. 23. Significant differences were p < 0.05. RESULTS: Sixty-four of 166 patients (38.6%) tested positive for opioids. Among them, 55.0% (35/64) had no history of prescription opioid use. Significant differences were observed when comparing the test results of the UDS with the patient reported history of prescribed opioids (p = 0.001). CONCLUSION: With a significant number of patients testing positive for opioids without evidence of a previous prescription, UDS may be beneficial for initial risk assessment for patients undergoing JA procedures.

Early Versus Delayed Mobilization Postoperative Protocols for Lateral Ankle Ligament Repair: A Systematic Review and Meta-analysis.

BACKGROUND: The majority of patients with an acute lateral ankle ligamentous injury are successfully treated nonoperatively with functional rehabilitation; however, a small proportion of these patients experience persistent chronic instability and may require surgical intervention. Delayed primary repair of the ruptured ligaments is most commonly indicated for these patients. Optimal rehabilitation after lateral ankle ligament repair remains unknown, as surgeons vary in how they balance protection of the surgical repair site with immobilization against the need for ankle joint mobilization to restore optimal postoperative ankle range of motion. PURPOSE: To compare early and delayed mobilization (EM and DM, respectively) postoperative protocols in patients undergoing primary lateral ankle ligament repair to determine optimal evidence-based rehabilitation recommendations. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a meta-analysis using the PubMed/Ovid MEDLINE database was performed (October 11, 1947 to October 16, 2017), searching for articles involving lateral ankle ligament repair. Postoperative protocols were reviewed and divided into 2 categories: EM (within 3 weeks of surgery) and DM (more than 3 weeks post surgery). Return to sport (RTS), outcome scores (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot scale and Karlsson score), radiographic outcomes (talar tilt and anterior drawer), and complications of both populations were recorded and statistically analyzed. RESULTS: A total of 28 of 1574 studies met the criteria for the final analysis, comprising 1457 patients undergoing primary lateral ankle ligament repair. The postoperative AOFAS score was significantly greater in the EM versus DM group (98.8 vs 91.9, respectively; P < .001), as was the postoperative Karlsson score (92.2 vs 90.0, respectively; P < .001). However, the EM group had significantly greater postoperative laxity on both the anterior drawer test (6.3 vs 3.9 mm, respectively; P < .001) and talar tilt test (5.1° vs 4.5°, respectively; P < .001). Also, the DM group had significantly lower rates of overall complications (3.1% vs 11.4%, respectively; P < .001) and skin wound complications (1.3% vs 3.8%, respectively; P = .005). RTS was not significantly different between groups (P = .100). CONCLUSION: Patients with EM postoperative protocols demonstrated improved functional outcomes; however, the EM group had increased objective laxity and a higher complication rate. Additional randomized studies are needed to definitively evaluate early versus delayed rehabilitation protocol timetables to optimize functional outcomes without compromising long-term stability.

Electronic Monitoring Of Mom's Schedule (eMOMS™): Protocol for a feasibility randomized controlled trial to improve postpartum weight, blood sugars, and breastfeeding among high BMI women.

BACKGROUND: Overweight and obesity are major risk factors for gestational diabetes among U.S. women. Evidence suggests that longer duration of breastfeeding among women with a history of gestational diabetes is associated with lower incidence of developing type 2 diabetes after pregnancy. Women may potentially benefit from a lifestyle change program that includes breastfeeding education and support. PURPOSE: To describe the design and justification of a combined breastfeeding, national Diabetes Prevention Program (DPP)-based feasibility randomized controlled trial, the electronic Monitoring Of Mom's Schedule (eMOMSTM) study. eMOMSTM compares the feasibility and efficacy of three interventions on six-month postpartum weight loss among women with a BMI ≥25. METHODS: The intervention is delivered via Facebook and includes three groups: DPP and breastfeeding (eMOMS1); DPP only (eMOMS2); and Usual Care (eMOMS3). Recruitment is ongoing at two clinical sites (rural and urban). A total of 72 women, 24 per group, will be randomly assigned to one of the three groups. It is anticipated that women in eMOMS1 will have greater weight loss and increased length of breastfeeding at three and six months postpartum compared to women in eMOMS2 and eMOMS3. Additional data will be collected on metabolic markers, anthropometrics, physical activity, nutrition, breastfeeding, and depression. Program cost will be compared to that of traditionally scheduled group meetings. Expected study completion date: October 2021. CONCLUSIONS: This study has the potential to define a high impact, cost effective intervention that can improve public health by reducing negative health outcomes associated with gestational diabetes among an at-risk population.

Contribution of the BioFire® FilmArray® Meningitis/Encephalitis Panel: Assessing Antimicrobial Duration and Length of Stay.

INTRODUCTION: Traditional evaluation of meningitis includes cerebrospinal fluid (CSF) culture and gram stain to pinpoint specific causal organisms. The BioFire® FilmArray® Meningitis/Encephalitis (ME) Panel has been implemented as a more timely evaluation method. This study sought to assess if the BioFire® ME Panel was associated with a decreased length of stay or decreased antimicrobial duration when used in the diagnosis of meningitis or encephalitis. METHODS: A case, historical-control, chart review was performed on patients admitted to a regional medical center with CSF pleocytosis during Cohort 1 (the year prior to BioFire® ME Panel implementation) and Cohort 2 (the year after BioFire® ME Panel implementation). Length of hospital stay, duration of antimicrobials, and BioFire® ME Panel result were gathered and analyzed. RESULTS: Average length of stay for both cohorts was about four hospital days. Approximately three-fourths of all patients received antibiotic/antiviral treatment with an average of three days duration. No significant differences were observed between groups. The mean (median) duration of antimicrobials in the year prior to and after the BioFire® ME Panel implementation was 3.6 (3) and 3.1 (2) days, respectively (p = 0.835). The mean (median) length of stay in the year prior to and after the BioFire® ME Panel implementation was 5.8 (4) and 5.4 (4) days, respectively (p = 0.941). Among the patients admitted after the implementation of the BioFire® ME Panel, 4.3 % (n = 2) had a positive bacterial result, 38.3% (n = 18) had a positive viral result, and 57.4% (n = 27) had a negative result. Of the 27 negative results, 77.8% (n = 21) were treated with antimicrobial medication. CONCLUSIONS: This study suggested there is no difference between length of stay or antimicrobial duration in presumed meningitis cases assessed with traditional methods as compared to the BioFire® ME Panel.

Physician Burnout in a Rural Kansas Community.

INTRODUCTION: Physician wellness and burnout are topics of intense discussion and study, however, less is known about rural physician burnout. The aim of this study was to assess levels of physician burnout in the rural Kansas community of Salina. METHODS: An electronic, confidential survey was conducted among 145 physicians with active privileges at the local health center and/or surgical center. The survey included demographic features, practice characteristics, and the abbreviated Maslach Burnout Inventory™ (aMBI). In addition, survey participants were invited to provide free-text responses to questions concerning specific causes of burnout and mechanisms to combat feelings of burnout. RESULTS: Of 145 invited, 76 physicians completed the survey. Thirty-six respondents self-identified as primary care physicians, 22 as subspecialists, and 18 as surgeons. aMBI scores for emotional exhaustion (EE), depersonalization (D) and personal accomplishment (PA) ranged from 0 to 18. The mean EE score was 8.4 (SD = 4.9), mean D score was 4.8 (SD = 3.9), and mean PA score was 15.2 (SD = 2.8). Using tertiles, physician burnout (i.e., those in the first tertile) for EE was 39% (30/76), D was 34% (26/76), and PA was 41% (31/75); 22% of physicians surveyed scored high on both EE and D as measured by tertiles, suggestive of more serious burnout. No significant differences in aMBI scores were observed for demographic features or practice characteristics; physicians who worked with medical students had higher PA scores. Contributing to burnout were demands of documentation and difficult patient encounters, while true time away might ameliorate rural physician burnout. CONCLUSIONS: As measured by aMBI constructs, burnout is prevalent among the responding rural physicians practicing in the Salina community.

Efficacy of Community-Based Exercise Therapy Among African American Patients With Peripheral Artery Disease: A Randomized Clinical Trial.

Importance: African American individuals are 2 times more likely than non-Hispanic white individuals to have peripheral artery disease (PAD). Structured community-based exercise therapy improves walking distance among patients with PAD, but these patients require motivation to adhere to therapy. Objective: To assess whether motivational interviewing (MI) is more efficacious than Patient-Centered Assessment and Counseling for Exercise (PACE) or control to improve walking distance in African American patients with PAD. Design, Setting, and Participants: In this 3-group randomized clinical trial, 174 African American patients with PAD were studied from May 1, 2012, to November 30, 2016, at health care centers, churches, and health fairs in Wichita, Kansas; Kansas City, Kansas, and Kansas City, Missouri. Interventions: Patients were randomized in a 1:1:1 fashion to 1 of 3 groups (57 to MI, 57 to PACE, and 60 to control). The 2 counseling interventions were delivered biweekly for 3 months and monthly for 3 months followed by a 6-month maintenance phase with limited contact. Control participants received a mailing at 3 and 9 months. Main Outcomes and Measures: The primary outcome was 6-month change in 6-minute walking performance. Secondary outcomes included 12-month change in walking performance and 6- and 12-month changes in quality of life. Results: A total of 174 African American patients (mean [SD] age, 64.2 [11.2] years; 128 [74.0%] female) were studied. At 6 months, mean (SE) change in walking distance by group was as follows: MI, -3.42 (4.55) m; PACE, 2.74 (6.00) m; and control, -0.18 (4.40) m. At 12 months, mean (SE) change in walking distance by group was as follows: MI, -7.75 (5.50) m; PACE, 13.75 (6.13) m; and control, -1.08 (5.73) m. Comparing each of the intervention arms (MI and PACE) with the control arm, no statistically significant increases in walking distance at 6 months (MI: change, -2.10 m; 95% CI, -16.54 to 12.35 m; PACE: change, 2.31 m; 95% CI, -11.36 to 15.97 m) or 12 months (MI: change, -5.56 m; 95% CI, -21.18 to 10.06 m; PACE: change, 14.24 m; 95% CI, -1.85 to 30.34 m) were found. Compared with MI, PACE resulted in a statistically significant increase in walking distance at 12 months of 19.80 m (95% CI, 3.33-36.28 m). Conclusions and Relevance: In a cohort of African American patients with PAD, MI was not efficacious in improving walking distance at 6 or 12 months. The results of this study do not support the use of MI to improve walking performance in African American patients with PAD. Trial Registration: ClinicalTrials.gov Identifier: NCT01321086.