Penn State Health Milton S. Hershey Medical Center (MSHMC) is a 628-bed non-profit, tertiary, research and academic medical center located in Hershey, Pennsylvania, servicing the Central Pennsylvania area. MSHMC is the region's only university-level academic medical center. The hospital is owned by the Penn State Health System and is the largest hospital in the system. MSHMC is affiliated with the Pennsylvania State University College of Medicine. MSHMC is also an ACS designated level I adult and pediatric trauma center and has a helipad to handle medevac patients. Attached to the medical center is the 122 bed Penn State Children's Hospital, which treats infants, children, adolescents, and young adults up to the age of 21.
Endoscopic management offers acceptable oncologic control in select patients with upper tract urothelial carcinoma (UTUC) while preserving renal function. Adjuvant intracavitary treatment with chemotherapy or Bacillus Calmette-Guérin (BCG) has been proposed to reduce recurrence risk. We aimed to evaluate the impact of adjuvant intracavitary treatment on ipsilateral UTUC recurrence following endoscopic management. We queried a multi-institutional cohort of patients who underwent endoscopic management for UTUC. Treatment groups were defined as no instillation, single post-operative instillation, or multiple instillations. Ipsilateral UTUC recurrence-free survival (RFS) was estimated using Kaplan-Meier curves and Cox proportional hazards models evaluated factors associated with recurrence. A total of 599 renal units, of which 43 received single instillation and 86 multiple instillations, in 334 patients treated endoscopically for UTUC were analyzed. The median follow-up time for patients without recurrence was 12 months (IQR 4–33). Multiple adjuvant instillations of any intracavitary treatment were associated with a significantly improved RFS (HR 0.52, 95
Choledocholithiasis is challenging to treat in patients who have undergone Roux-en-Y gastric bypass (RYGB). Laparoscopic transcystic common bile duct exploration (LTCBDE) performed at the time of the cholecystectomy is an alternative treatment modality that has the potential to reduce hospital length of stay (LOS) and postoperative morbidity. This is an IRB-approved, single-academic institution retrospective cohort study analyzing electronic medical records of patients with RYGB anatomy who underwent LTCBDE for choledocholithiasis between 2021 and 2025. The primary outcome of interest was procedural response. Secondary outcomes of interest included technical response rates, operative and 30-day postoperative complications. Hospital and postoperative LOS were compared between admitting services. Nineteen patients with RYGB anatomy underwent LTCBDE and concomitant cholecystectomy. Technical response was achieved in 100
Cognitive behavioral therapy (CBT) is currently recognized as the most effective treatment for adults with eating disorders (EDs); however, few studies have examined CBT’s efficacy for younger patients. In this chapter, we describe how to adapt CBT for children and adolescents with EDs. Similar to the approach used with adults, CBT for younger patients involves an array of interventions designed to modify beliefs and behaviors related to eating, weight, and shape. These include developing a clinical formulation, psychoeducation, enhancing motivation, open weighing, meal planning, self-monitoring, cognitive restructuring, exposure therapy, and relapse prevention. Individual CBT for children and adolescents with EDs should be augmented with family involvement, with the frequency and format of family sessions varying as a function of the patient’s age, symptom pattern and severity, and other considerations. Particularly during the early phase of treatment for underweight patients, family sessions focus on coaching the patient’s caregivers to support their child with normalized eating and weight restoration. As patients become more active participants in treatment and behavior change, family involvement is reduced gradually.
Importance:Anecdotal accounts suggest an increase in problems initiating buprenorphine (BUP) treatment among individuals using illicitly manufactured fentanyl. Limited empirical data illuminate these challenges. Objective:To determine the prevalence of clinician-reported problems initiating BUP treatment among patients using fentanyl and describe clinical strategies used to overcome engagement challenges. Design, Setting, and Participants:For this survey study, an online survey was pilot tested and refined with a convenience sample of physicians. The final survey included 96 items and took less than 15 minutes to complete. The survey queried patients' use of fentanyl, BUP induction problems (precipitated or prolonged withdrawal), strategies to overcome induction problems, clinician characteristics, and practice characteristics. Eligible clinicians initiated BUP for at least 10 patients with opioid use disorder in the past year and at least 1 patient in the past 90 days. The survey was live from June 2, 2023, to March 18, 2024. Main Outcome and Measures:The main outcome of interest was precipitated and/or prolonged opioid withdrawal. Descriptive statistics are reported, and logistic regression was used to identify factors associated with BUP initiation problems. Results:A random sample of physicians and advanced practice clinicians in the US Drug Enforcement Administration (DEA) registrant dataset from October 2022 (n = 3141) were invited to participate; of 2485 eligible for inclusion, 649 (26.1%) completed the prescreen survey. Of 421 (64.9%) eligible to complete the survey, the final sample included 396 (94.1%) clinicians who completed at least 50% of the survey items. Of 390 participants, 284 (72.8%) reported problems when initiating BUP in patients using fentanyl, with 242 of 394 (61.4%) reporting patients' experiencing precipitated withdrawal. A total of 264 or 392 participants (67.3%) reported modifying their standard induction procedures, changing how they counsel patients, or changing both medication and counseling protocols. In multivariable modeling, clinicians were more likely to report problems initiating BUP in patients if they had a DEA waiver to treat more than 100 patients (OR, 1.92; 95% CI, 1.08-3.40), vs those waivered to treat fewer patients; if they reported at least 75% of their patients using fentanyl (OR, 6.31; 95% CI, 2.59-15.35), vs no patients; or if they inducted patients in noninpatient settings (OR, 2.79; 95% CI, 1.39-5.61), vs inpatient settings. Conclusions and Relevance:In this survey study of clinician-reported problems initiating BUP treatment, clinicians working in high-volume noninpatient settings reported more problems initiating BUP in patients using fentanyl, and many reported changing their clinical practices in response to these problems. Further research is warranted to match alternate BUP induction strategies by clinical settings.
BACKGROUND AND OBJECTIVES:Patients using fentanyl have worse treatment outcomes; however, little is known about other drugs that complicate treatment. METHODS:A national survey (n = 396) was conducted using a random sample of clinicians waivered to prescribe buprenorphine in the United States. This study reports the results of a single survey item on clinicians' perceptions of other drugs, besides IMF, complicating treatment. RESULTS:Clinicians reported methamphetamine (86.4%), synthetic cannabinoids (42.7%), and xylazine (41.4%) were complicating treatment; reports varied by geographic region. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE:Rapid clinician surveys can provide real-time data on changing patterns of drug use's impact treatment outcomes.
