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Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.

Introduction Patients with rheumatologic disease experience higher rates of comorbid mental health diseases than those without. Although mental health services (MHS) can improve musculoskeletal functional outcomes, access to MHS has been limited among vulnerable populations in the United States (US). The purpose of this study was to investigate contemporary patterns of severe psychological distress and receipt of MHS among immigrant populations with rheumatologic disease in the US. Methods The National Health Interview Survey was queried for patients with rheumatologic disease from 2009 to 2018. Patient demographics, severe psychological distress, and receipt of MHS were collected and/or calculated. Multivariable logistic regressions assessed for factors associated with decreased receipt of MHS and severe psychological distress. Results Immigrant patients with rheumatologic disease had higher rates of severe psychological distress than US-born patients (7.7% vs. 6.5%, p  < 0.001), but were less likely to access MHS (8.3% vs. 11.0%, p  < 0.001). Among immigrant patients, factors associated with lower MHS receipt included being Black (AOR 0.50, 95% CI 0.32–0.77, p  = 0.002), Hispanic (AOR 0.80, 95% CI 0.30–1.00, p  = 0.050), Asian (AOR 0.44, 95% CI 0.31–0.63, p  < 0.001), older ( p  < 0.001), uninsured ( p  < 0.001), and having self-reported poor health ( p  < 0.001). Discussion Immigrant patients with rheumatologic disease in the US had higher rates of severe psychological distress yet were less likely to receive MHS compared to US-born patients. Immigrants with rheumatologic illness were less likely to receive MHS if they were male, Black, Hispanic, Asian, older, lower income, or uninsured. This lack of MHS receipt may contribute to disparities in functional outcomes seen in immigrant minorities with musculoskeletal disease. Key Points • Immigrant patients with rheumatologic disease in the US had higher rates of severe psychological distress yet were less likely to receive MHS compared to US-born patients between 2009 and 2018 • Immigrants with rheumatologic illness were less likely to receive MHS if they were Black, Hispanic, Asian, older, lower income, or uninsured • Future efforts to carefully screen for mental health diseases in these vulnerable patient populations should be made while exploring patient-specific cultural considerations of MHS receipt

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under physiologic loads when treated with a knotless fiber tape construct and a solid screw. Methods: Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple physiologic loads representing guarded walking (69N), walking (138N), and running (207N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine type of fixation for each cadaver: a solid screw or knotless fiber tape construct. Once fixation was completed, specimens were cyclically loaded for 10,000 cycles at physiologic loads and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. Results: Diastasis mean values were confirmed to be >2mm for all load bearing conditions in the injury model. Post-treatment, diastasis was significantly reduced when compared to the sectioned conditions (p=0.00) for both treatment options. Non-inferiority analyses showed that the knotless fiber tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. Conclusion: Under physiologic loads, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless fiber tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state.

[...]EDs have begun to increase their capacity to treat opioid use disorder (OUD) in an evidence based manner [2]. Extensive research demonstrates that using medication for addiction treatment (MAT) with buprenorphine to treat OUD effectively increases retention in treatment, reduces illicit opioid use, and decreases all-cause and opioid-related mortality [3-6]. Because many patients with OUD use the ED as a primary source of care, our ED designed an evidence-based pathway to prescribe buprenorphine as part of an addiction treatment protocol for patients seeking to overcome their opioid addiction. [...]we sent monthly emails to the department from the ED's Executive Vice Chair reminding clinicians of the department's OUD initiative and providing success stories and personalized public acknowledgements to clinicians who had successfully initiated evidence based treatment to patients with OUD in the ED.

Background Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process. Methods/Design The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment : We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants’ impressions about the current process. Adaptation and implementation : We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process’ feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units. Evaluation : Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process. Data analysis : The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability. Discussion The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients. Trial registration ClinicalTrials.gov identifier: NCT02267174 . Date of registration October 16, 2014.

The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with non-opioid pain management and patient reported outcome measures (PROMs) following arthroscopic partial meniscectomy and/or chondroplasty. 175 patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were pre-operatively stratified into low/normal resilience or high resilience groups as measured by the BRS. Satisfaction with non-opioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAPHS) questionnaire, and various PROMs were measured at 3 months and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups. Analysis revealed no statistically significant differences between the low/normal resilience group and the high resilience group with regards to satisfaction with non-opioid pain control or PROMs assessed at 3 or 6 month follow-ups. VAS pain, KOOS pain, KOOS ADL, KOOS QOL, SANE Knee, VR-12 (Physical Component Score), and VR-12 (Mental Component Score) outcome measures all followed expected trajectories after surgery without a statistically significant difference between resilience groups. This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient reported functional outcome or satisfaction with a non-opioid pain regimen following knee arthroscopy.

The risks, benefits, and utilities of multiplex panels for breast cancer susceptibility are unknown, and new counseling and informed consent models are needed. We sought to obtain patient feedback and early outcome data with a novel tiered-binned model for multiplex testing. BRCA1/2-negative and untested patients completed pre- and posttest counseling and surveys evaluating testing experiences and cognitive and affective responses to multiplex testing. Of 73 patients, 49 (67%) completed pretest counseling. BRCA1/2-negative patients were more likely to proceed with multiplex testing (86%) than those untested for BRCA1/2 (43%; P < 0.01). Many patients declining testing reported concern for uncertainty and distress. Most patients would not change anything about their pre- (76%) or posttest (89%) counseling sessions. Thirty-three patients (72%) were classified as making an informed choice, including 81% of those who proceeded with multiplex testing. Knowledge increased significantly. Anxiety, depression, uncertainty, and cancer worry did not significantly increase with multiplex testing. Some patients, particularly those without prior BRCA1/2 testing, decline multiplex testing. Most patients who proceeded with testing did not experience negative psychological responses, but larger studies are needed. The tiered-binned approach is an innovative genetic counseling and informed consent model for further study in the era of multiplex testing.

Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.

Membrane inlet mass spectrometry (MIMS) is a well-established method used to detect gases dissolved in solution through the use of a semipermeable hydrophobic membrane that allows the dissolved gases, but not the liquid phase, to enter a mass spectrometer. Interest in the unique biological activity of azanone (nitroxyl, HNO) has highlighted the need for new sensitive and direct detection methods. Recently, MIMS has been shown to be a viable method for HNO detection with nanomolar sensitivity under physiologically relevant conditions (Chapter 2). In addition, this technique has been used to explore potential biological pathways to HNO production (Chapter 3). Nitrenes are reactive intermediates containing neutral, monovalent nitrogen atoms. In contrast to alky- and arylnitrenes, carbonylnitrenes are typically ground state singlets. In joint synthesis, anion photoelectron spectroscopic, and computational work we studied the three nitrenes, benzoylnitrene, acetylnitrene, and trifluoroacetylnitrene, with the purpose of determining the singlet-triplet splitting (ΔEST = E S – ET) in each case (Chapter 7). Further, triplet ethoxycarbonylnitrene and triplet t-butyloxycarbonylnitrene have been observed following photolysis of sulfilimine precursors by time-resolved infrared (TRIR) spectroscopy (Chapter 6). The observed growth kinetics of nitrene products suggest a contribution from both the triplet and singlet nitrene, with the contribution from the singlet becoming more prevalent in polar solvents.

Conventional genome engineering with CRISPR–Cas9 creates double-strand breaks (DSBs) that lead to undesirable byproducts and reduce product purity. Here we report an approach for programmable integration of large DNA sequences in human cells that avoids the generation of DSBs by using Type I-F CRISPR-associated transposases (CASTs). We optimized DNA targeting by the QCascade complex through protein design and developed potent transcriptional activators by exploiting the multi-valent recruitment of the AAA+ ATPase TnsC to genomic sites targeted by QCascade. After initial detection of plasmid-based integration, we screened 15 additional CAST systems from a wide range of bacterial hosts, identified a homolog from Pseudoalteromonas that exhibits improved activity and further increased integration efficiencies. Finally, we discovered that bacterial ClpX enhances genomic integration by multiple orders of magnitude, likely by promoting active disassembly of the post-integration CAST complex, akin to its known role in Mu transposition. Our work highlights the ability to reconstitute complex, multi-component machineries in human cells and establishes a strong foundation to exploit CRISPR-associated transposases for eukaryotic genome engineering. Large DNA sequences are integrated into human cells using RNA-guided CRISPR-associated transposases.