University of New England College of Osteopathic Medicine

Objectives Emergency departments (ED) are increasingly implementing community health worker (CHW) and peer recovery specialist (PRS) programs to engage patients with substance use disorders and link them to harm reduction and addiction treatment services. This scoping review aims to provide a broad overview of current research on ED-based CHW and PRS programs in North America. Methods We conducted a comprehensive database search on PubMed, Embase, MEDLINE/OVID, and World of Science through December 31, 2022. Articles were screened for inclusion by 2 reviewers with conflicts resolved by a third reviewer. Data extraction from full-text articles was completed by 3 reviewers and checked for accuracy by a separate reviewer. Results We screened 12,187 abstracts, reviewed 398 full-text articles, and selected 64 papers about 35 distinct programs for inclusion. Study design included a mix of retrospective and prospective analyses, including a few randomized control trials. Core program components include services navigation (97.1%), motivational interviewing and/or a brief intervention (65.7%), harm reduction services (42.9%), and case management (28.6%). Most programs evaluating addiction treatment engagement noted comparative increase in treatment engagement after program implementation, which includes initiation of medication for opioid use disorder and outpatient treatment engagement. Programs evaluating ED utilization noted a reduction in ED visits after program implementation. Comparative outcome research about overdose, hospitalizations, mortality, and cost were limited. Conclusion ED-based CHW and PRS programs varied in design and services provided. Most studies measuring engagement reported favorable effects, although with limited effect size and heterogenous study quality, design, and metrics that limit generalizability. Future research should evaluate program effectiveness and identify key elements of successful ED-based programs to inform implementation.

PROBLEM:A core competency of medical education is preparing physicians to effectively navigate challenging clinician-patient relationships. Balint groups are used with residents and practicing physicians to increase interpersonal skills and reduce burnout but are rarely included in undergraduate medical education. Virtual Balint offerings recruiting medical students from across programs represent a way to increase accessibility. APPROACH:The American Balint Society (ABS) instituted a pilot feasibility project to provide virtual Balint groups for medical students. Students were recruited using informational brochures sent to 155 US allopathic and osteopathic medical schools. 150 students from 26 medical schools were recruited and divided into groups of 10-11, comprised of students from different schools and years of education and led by two experienced ABS credentialed leaders. Each group met monthly four times via Zoom, with new groups initiated each semester from Fall 2023 to Spring 2025. OUTCOMES:Overall, a total of 150 medical students from 26 different medical schools participated, some for several semesters. Following the Fall 2023 and 2024 groups, participants were surveyed. In total, 31 of 83 (37%) responded; results indicated students reported interpersonal skill improvement, particularly in awareness of the interpersonal context, perspective-taking skills, active listening, and an appreciation for their interpersonal impact on their patients. Qualitative responses indicated a desire for Balint groups to be included in their medical education. NEXT STEPS:The ABS intends to continue and expand student virtual Balint groups. The goal is to provide Balint opportunities for students at as many medical schools as possible, while providing leadership training for faculty at those schools and initiating research demonstrating valuable outcomes of Balint education.

PURPOSE:Lisfranc injuries, also referred to as tarsometatarsal joint injuries, are relatively uncommon within the general population and can possess profound clinical implications, especially for elite athletes. Existing follow-up and return to sport (RTS) protocols remain poorly defined and variable based on surgeon preference or institutional protocols. The purpose of this study was to both perform a systematic review and determine if consensus on postoperative protocols and RTS timelines could be reached among an expert panel of orthopaedic foot and ankle surgeons who manage Lisfranc injuries in the elite athlete. METHODS:The systematic review evaluated the post-operative management of sports-related Lisfranc injuries. A consensus process was then conducted using a modified Delphi technique with four rounds of questionnaires. General consensus was defined as 75%-85% agreement, strong consensus as 86%-99% agreement and unanimous consensus as 100% agreement. RESULTS:The systematic review found patients with ligament Lisfranc injuries were permitted to begin weightbearing at an average of 3.5 weeks. The mean time for these athletes to RTS was 8.9 months. Those with bony Lisfranc injuries were allowed to partially weightbear at 4.5 weeks, on average. Bony Lisfranc injuries treated with open reduction and internal fixation (ORIF) allowed the athlete to RTSs at a median of 8 weeks (range 3-12 weeks). There are nine consensus statements presented that illustrate the expected follow-up and RTS milestones. There was unanimous agreement that the athlete can expect to return to their sport 4-6 months postoperatively and athletes with unstable ligament injuries can expect to return to full weightbearing 8-12 weeks postoperatively. CONCLUSIONS:This study integrates expert consensus and systematic review findings to establish evidence-based guidelines for returning athletes to sport following Lisfranc injuries. Consensus and literature findings aligned, indicating that most athletes progress to full weightbearing by 8-12 weeks and RTS within 4-6 months postoperatively. Over 90% of athletes successfully resumed play, underscoring the effectiveness of structured, phase-based rehabilitation. These data provide a standardised framework to guide clinicians in optimising recovery and ensuring a safe, efficient RTS. LEVEL OF EVIDENCE:Level V.

We describe a case of establishing cardiopulmonary bypass (CPB) before general anesthesia in a person who has an obstructive right atrial myxoma protruding into the right ventricle (RV). A 27-year-old female endorsed shortness of breath on exertion, dry cough, and palpitations, with a cardiac MRI exhibiting a severely enlarged right atrium (RA) with a 65 mm x 40 mm mass. The mass obstructed the tricuspid valve from closing and extended into the RV, leading to an ejection fraction (EF) of 49%. The obstruction caused concern for cardiovascular collapse due to hypotension and bradycardia that may be provoked by inducing general anesthesia. Under local sedation, the femoral vessels were cannulated, CPB was initiated, and the patient received general anesthesia. A median sternotomy was completed, and traditional CPB was established. After the heart was arrested, the RA was opened, and the mass was resected along with a full-thickness section of the RA. This case report supports preoperative CPB for patients undergoing general anesthesia to correct a cardiac mass that is obstructing central venous return.