Objective: To determine whether alcohol use leads to prolonged clinical recovery or increased severity of concussion symptoms in National Collegiate Athletic Association (NCAA) athletes. Design: Prospective observational study. Setting: Clinical institutions. Participants: Athletes from the NCAA Concussion Assessment Research and Education consortium who sustained a concussion from 2014 to 2021. Interventions: Athletes were divided into 2 groups, those reporting alcohol use postinjury and those reporting no alcohol use postinjury. Main Outcome Measures: Symptom recovery was evaluated as time (in days) from injury to clearance to return to unrestricted play (days until URTP). Severity of concussion symptoms was assessed using the Standardized Sport Concussion Assessment Tool (SCAT3) symptom severity, headache severity, difficulty concentrating, and difficulty remembering scores. These scores were taken a median of 6.6 [interquartile range (IQR) = 4.0-10] and 6 (IQR = 4.0-9.0) days after injury for those who did and did not consume alcohol postinjury respectively and compared with baseline SCAT3 scores. Results: Four hundred eighty four athletes from the data set had complete data for exposure and outcome. The adjusted mean number of days until URTP for athletes reporting alcohol use postinjury [23.3; 95% confidence interval (CI), 20.0-27.2; days] was incidence rate ratio (IRR) 1.32 (95% CI, 1.12-1.55; P < 0.001) times higher than for athletes who reported no alcohol use postinjury [17.7 (95% CI, 16.1-19.3) days]. Postinjury alcohol was not associated with severity of concussion symptoms ( P 's < 0.05). Conclusion: Self-reported postinjury alcohol use is associated with prolonged recovery but not severity of concussion symptoms in collegiate athletes. This may inform future clinical recommendations regarding alcohol consumption after concussion.

Abstract Background We investigated in older adult non-cardiac surgical patients whether receipt of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased incidence of postoperative cardiovascular complications. Methods We retrospectively extracted the information for patients with age ≥ 65 years who had inpatient non-cardiac surgery with a duration of ≥ 1 h from the American College of Surgeons-National Surgical Quality Improvement Program registry data acquired at the University of Washington Medical Center. We compared patients who received NSAIDs perioperatively to those who did not receive NSAIDs, on the two composite outcomes: (1) the incidence of postoperative cardiovascular complications within 30 days of the surgery, and (2) the incidence of combined postoperative gastrointestinal and renal complications, and length of postoperative hospital stay. We used separate multivariable logistic regression models to analyze the two composite outcomes and a Poisson regression model for the length of hospital stay. Results The receipt of perioperative NSAIDs was not associated with postoperative cardiovascular complications (estimated odds ratio (OR), 1.78; 95% confidence interval (CI), 0.97 to 3.25; P = 0.06), combined renal and gastrointestinal complications (estimated OR, 1.30; 95% CI, 0.53 to 3.20; P = 0.57), and length of postoperative hospital stay in days (incidence rate ratio, 1.06; 95% CI, 0.93 to 1.21; P = 0.39). Conclusions In older adult non-cardiac surgical patients, receipt of perioperative NSAIDs was not associated with increased incidences of postoperative cardiovascular complications, and renal and gastrointestinal complications within 30 days after surgery, or length of postoperative hospital stay.

An interspinous spacer is a minimally invasive implantable device for the treatment of lumbar spinal stenosis. The in situ implant may prevent safe and successful spinal anesthesia because its position can obstruct the path of the spinal needle. Lumbar neuraxial ultrasonography has been shown to aid in performance of neuraxial anesthesia in patients with challenging anatomy. Currently, there are no reported cases of ultrasound-assisted spinal anesthesia in patients with interspinous spacers. We present a case in which ultrasonography assisted the successful administration of a spinal anesthetic by avoiding an indwelling lumbar interspinous spacer.

Objective: The association between postictal electroencephalogram (EEG) suppression (PES), autonomic dysfunction, and Sudden Unexpected Death in Epilepsy (SUDEP) remains poorly understood. We com-pared PES on simultaneous intracranial and scalp-EEG and evaluated the association of PES with postictal heart rate variability (HRV) and SUDEP outcome.Methods: Convulsive seizures were analyzed in patients with drug-resistant epilepsy at 5 centers. Intracranial PES was quantified using the Hilbert transform. HRV was quantified using root mean square of successive dif-ferences of interbeat intervals, low-frequency to high-frequency power ratio, and RR-intervals.Results: There were 64 seizures from 63 patients without SUDEP and 11 seizures from 6 SUDEP patients. PES occurred in 99% and 87% of seizures on intracranial-EEG and scalp-EEG, respectively. Mean PES duration in intracranial and scalp-EEG was similar. Intracranial PES was regional (<90% of channels) in 46% of seizures; scalp PES was generalized in all seizures. Generalized PES showed greater decrease in postictal parasympa-thetic activity than regional PES. PES duration and extent were similar between patients with and without SUDEP.Conclusions: Regional intracranial PES can be present despite scalp-EEG demonstrating generalized or no PES. Postictal autonomic dysfunction correlates with the extent of PES. Significance: Intracranial-EEG demonstrates changes in autonomic regulatory networks not seen on scalp-EEG.(c) 2022 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

Objectives: We tested the hypothesis that patients who received methocarbamol postoperatively experience less severe pain and require smaller doses of opioids than those who did not receive methocarbamol. Materials and Methods: This is a retrospective cohort study of patients undergoing surgery involving the musculoskeletal system. Of 9089 patients, 704 received methocarbamol during 48 hours postoperatively, while 8385 did not receive methocarbamol. The patients who received methocarbamol postoperatively and the patients who did not receive methocarbamol were compared on the time-weighted average (TWA) pain score and opioid dose requirements in morphine milligram equivalents (MME) during the first 48 hours postoperatively, using propensity score-weighted regression models to adjusting for preoperative and intraoperative covariates. Results: Postoperative 48-hour TWA pain scores were 5.5±1.7 (mean±SD), and 4.3±2.1 for methocarbamol and non-methocarbamol patients. Postoperative 48-hour opioid dose requirements in MME were 276 [170–347] (median [interquartile range (IQR)]) mg, and 190 [60–248] mg for methocarbamol and non-methocarbamol patients. In propensity score-weighted regression models, receiving methocarbamol postoperatively was associated with 0.97-point higher postoperative TWA pain score (95% CI, 0.83–1.11; P<0.001), and 93.6-MME higher postoperative opioid dose requirements (95% CI, 79.9 to 107.4; P<0.001), compared with not receiving methocarbamol postoperatively. Discussion: Postoperative methocarbamol was associated with significantly higher acute postoperative pain burden and opioid dose requirements. Although the results of the study are influenced by residual confounding, they suggest a limited—if any—benefit of methocarbamol as an adjunct of postoperative pain management.

Background We tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine. Methods This is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO 2 ) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates. Results Postoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P =0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P =0.02). Conclusions Continuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.

IMPORTANCE COVID-19 vaccine boosters or third doses are recommended for adolescents and adults who completed their initial COVID-19 vaccine course more than 5 months prior. Minimal data are available on COVID-19 vaccine booster or third dose reactogenicity among pregnant and lactating individuals. OBJECTIVE To describe the reactions to the booster or third dose of the COVID-19 vaccine and vaccine experiences among pregnant and lactating individuals. DESIGN, SETTING, AND PARTICIPANTS Beginning in October 2021, a follow-up Research Electronic Data Capture (REDCap) survey regarding a COVID-19 vaccine booster or third dose was sent to 17 504 participants in an ongoing online prospective cohort study on COVID-19 vaccines among pregnant and lactating individuals. A convenience sample of adults enrolled in the online prospective study who were pregnant, lactating, or neither pregnant nor lactating at the time of their booster or third dose was eligible for this follow-up survey; 17 014 (97.2%) completed the follow-up survey. EXPOSURE Receipt of a booster or third dose of the COVID-19 vaccine. MAIN OUTCOMES AND MEASURES Self-reported vaccine reactions less than 24 hours after the dose. RESULTS As of April 4, 2022, 17 014 eligible participants (mean [SD] age, 33.3 [3.5] years) responded to the booster or third dose survey; of these, 2009 (11.8%) were pregnant at the time of their booster or third dose, 10 279 (60.4%) were lactating, and 4726 (27.8%) were neither pregnant nor lactating. After a COVID-19 booster or third dose, most individuals (14 074 of 17 005 [82.8%]) reported a local reaction, and 11 542 of 17 005 (67.9%) reported at least 1 systemic symptom. Compared with individuals who were neither pregnant nor lactating, pregnant participants were more likely to report any local reaction to a COVID-19 booster or third dose (adjusted odds ratio [aOR], 1.2; 95% CI, 1.0-1.4; P=.01) but less likely to report any systemic reaction (aOR, 0.7; 95% CI, 0.6-0.8; P<.001). Most pregnant (1961 of 2009 [97.6%]) and lactating (9866 of 10 277 [96.0%]) individuals reported no obstetric or lactation concerns after vaccination. CONCLUSIONS AND RELEVANCE This study suggests that COVID-19 vaccine boosters or third doses were well tolerated among pregnant and lactating individuals. Data to evaluate tolerability of boosters or additional doses among pregnant and lactating individuals will be important as they are considered for these populations.

This cohort study investigates short-term reactions associated with COVID-19 vaccines among pregnant and lactating individuals vs individuals neither pregnant nor lactating but planning pregnancy.

Objective Traditional public health surveillance of nonfatal opioid overdose relies on emergency department (ED) billing data, which can be delayed substantially. We compared the timeliness of 2 new data sources for rapid drug overdose surveillance—emergency medical services (EMS) and syndromic surveillance—with ED billing data. Methods We used data on nonfatal opioid overdoses in Kentucky captured in EMS, syndromic surveillance, and ED billing systems during 2018-2019. We evaluated the time-series relationships between EMS and ED billing data and syndromic surveillance and ED billing data by calculating cross-correlation functions, controlling for influences of autocorrelations. A case example demonstrates the usefulness of EMS and syndromic surveillance data to monitor rapid changes in opioid overdose encounters in Kentucky during the COVID-19 epidemic. Results EMS and syndromic surveillance data showed moderate-to-strong correlation with ED billing data on a lag of 0 (r = 0.694; 95% CI, 0.579-0.782; t = 9.73; df = 101; P < .001; and r = 0.656; 95% CI, 0.530-0.754; t = 8.73; df = 101; P < .001; respectively) at the week-aggregated level. After the COVID-19 emergency declaration, EMS and syndromic surveillance time series had steep increases in April and May 2020, followed by declines from June through September 2020. The ED billing data were available for analysis 3 months after the end of a calendar quarter but closely followed the trends identified by the EMS and syndromic surveillance data. Conclusion Data from EMS and syndromic surveillance systems can be reliably used to monitor nonfatal opioid overdose trends in Kentucky in near–real time to inform timely public health response.

Background: There is currently insufficient data describing how new medications are provided to older adult ambulatory patients with dementia in the United States (US). Objectives: To describe characteristics of ambulatory care visits for adults >= 65 years old and investigate differences in prescribing of new medications between patients with and without dementia. Methods: We conducted a population-based cross-sectional study using the 2016 National Ambulatory Medical Care Survey (NAMCS) in the US. Non-perioperative ambulatory care visits of patients >= 65 years old with sampling weights were used to provide national estimates of visits. Baseline characteristics were compared between visits for patients with and without dementia using Pearson's chi square or Student's t-tests. We used multivariable logistic regression to estimate the odds of receiving a new medication. Results: 218,182,131 non-perioperative ambulatory care visits of patients >= 65 years old were included, 2.1% of which were for patients with dementia; these patients were older on average and had more comorbidities and higher ambulatory care utilization than those without dementia. New medications were provided at 26.3% of visits for patients with dementia. After adjusting for confounders, there was no statistically significant difference in odds of a new medication being provided between visits for patients with and without dementia (odds ratio [OR], 0.555; 95% confidence interval [CI], 0.183-1.678). Differences were seen in the provision of cholinesterase inhibitors, antipsychotics, and central nervous system agents at visits for patients with dementia (p = 0.0011, <0.0001, and 0.0011 respectively). Conclusion: While fewer visits for patients with dementia provided new medications compared to patients without dementia, after adjusting for confounders no significant difference were identified. Significant differences were seen in the classes of new medications provided. Further investigation is needed to evaluate new medication usage and the utility of pharmacists in the care of patients with dementia at an outpatient setting.

BackgroundAlthough Kentucky pharmacists recently gained authority to provide protocol-driven care for 13 conditions, provision of prescription hormonal contraception (HC) services is not currently authorized. A board-approved protocol allowing for provision of nonprescription over-the-counter (OTC) emergency contraception (EC) was recently approved by the Kentucky Board of Pharmacy but has yet to be implemented.ObjectivesThe objectives of this study were (1) to assess Kentucky pharmacists’ interest in providing prescription HC and OTC EC services via protocol and (2) to identify perceived benefits/barriers regarding provision of prescription HC.MethodsAn online questionnaire was disseminated electronically to a convenience sample of Kentucky pharmacists. The questionnaire collected (1) demographic information, (2) opinions regarding provision of prescription HC and OTC EC, and (3) perceived benefits and barriers regarding provision of prescription HC. For analysis, responses were limited to pharmacists in community-based practice. McNemar’s test was used to identify statistically significant differences in support by dosage form. In addition, a multivariable logistic regression model was used to examine associations between demographic factors and support for pharmacist provision of prescription HC.ResultsWe received 151 responses from community-based pharmacists. Support for provision of prescription HC was highest for oral (61%) and transdermal (54%) forms. We found no statistically significant differences in support among demographic factors other than number of years in practice, with more recent graduates being at higher odds of support. In addition, time, reimbursement, training, and belief in the need for pelvic exams were the most commonly cited barriers to implementation. With regard to OTC EC provision, pharmacists were largely supportive (62%) and confident in their abilities.ConclusionsCommunity-based pharmacists in Kentucky are supportive of provision of oral, vaginal, and transdermal prescription HC as well as OTC EC via protocol. Barriers, including time, reimbursement, training, and belief in the need for pelvic exams, should be addressed to increase support for prescription HC provision.

SummaryBackgroundChronic opioid use is associated with poorer clinical outcomes in inflammatory bowel disease.AimsTo investigate an association between chronic opioid use and persistence with biologic agents in management of inflammatory bowel disease.MethodsA total of 16 624 patients diagnosed with inflammatory bowel disease and receiving a first‐time biologic prescription from 2011 to 2016 were identified retrospectively from the Truven MarketScan Database. A cohort of 1768 patients were identified as chronic opioid users utilising outpatient prescription claims. Utilisation patterns of biologic therapies were assessed from inpatient administration and outpatient claims data, including persistence calculations. Information on healthcare utilisation and common comorbidities was also collected. A Cox regression model was constructed to assess the hazard of chronic opioid use on early discontinuation of biologic therapy controlling for disease severity.ResultsA mean 1.5 different biologic agents were utilised by inflammatory bowel disease patients with chronic opioid use (vs 1.37 in the comparator group; P < 0.0001). A lower proportion of the chronic opioid use cohort persisted on biologic therapies to the end of the study period (16.2% vs 33.5% P < 0.0001). Inflammatory bowel disease patients with chronic opioid use utilised more healthcare resources and had a higher rate of comorbidities than the reference cohort. Patients with chronic opioid use were 23% more likely (hazard ratio 1.23; 95% CI [1.16‐1.31]) to be non‐persistent with biologic therapy while accounting for relevant markers of disease acuity.ConclusionsChronic opioid use is associated with increased hazard of biologic discontinuation in inflammatory bowel disease. Symptoms of opioid withdrawal may mimic IBD flares thereby leading providers to inappropriately switch biologic therapies and compromise disease control.

The recent joint statement from the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anesthesia and Pain Therapy (ESRA) recommends neuraxial and peripheral nerve blocks for patients with coronavirus disease 2019 (COVID-2019) illness. The benefits of regional anesthetic and analgesic techniques on patient outcomes and healthcare systems are evident. Regional techniques are now additionally promoted as a mechanism to reduce aerosolizing procedures. However, caring for patients with COVID-19 illness requires rapid redefinition of risks and benefits-both for patients and practitioners. These should be fully considered within the context of available evidence and expert opinion. In this Daring Discourse, we present two opposing perspectives on adopting the ASRA/ESRA recommendation. Areas of controversy in the literature and opportunities for research to address knowledge gaps are highlighted. We hope this will stimulate dialogue and research into the optimal techniques to improve patient outcomes and ensure practitioner safety during the pandemic.

ObjectiveThe aim of this project was to explore changing patterns in patient refusal to transport by emergency medical services for classified heroin overdoses and possible implications on heroin overdose surveillance in Kentucky.IntroductionAs a Centers for Disease Control and Prevention Enhanced State Opioid Overdose Surveillance (ESOOS) funded state, Kentucky started utilizing Emergency Medical Services (EMS) data to increase timeliness of state data on drug overdose events in late 2016. Using developed definitions of heroin overdose for EMS emergency runs, Kentucky analyzed the patterns of refused/transported EMS runs for both statewide and local jurisdictions. Changes in EMS transportation patterns of heroin overdoses can have a dramatic impact on other surveillance systems, such as emergency department (ED) claims data or syndromic surveillance (SyS) data.MethodsAs part of the ESOOS grant, Kentucky receives all emergency-only EMS runs monthly from Kentucky Board for Emergency Medical Services, Kentucky State Ambulance Reporting System data. Heroin cases were classified based on text and medications (Narcan) administered, with comparisons to historic data discussed elsewhere (Rock & Singleton, 2018). Transportation classifications are based on EMS standard elements defining treatment with transportation vs refusal to transport to hospital and canceled runs were excluded. Initial analysis included trend analysis at state and local levels, as well as demographic comparisons of refusal vs transported heroin overdose encounters.ResultsStatewide trends in EMS heroin overdoses with refusal transport significantly increased from 5% (n=42) in 2016 quarter three to 22% (n=290) in 2018 quarter two (Fig 1). Initial demographic analysis does not show any significant difference between refusals/transported for age, gender, or race. However, there are significant differences among geographic regions in Kentucky with heroin encounter refusal proportion ranging from 3%-48% in 2018 quarter two. Specifically, one urban area (Fig 2) shows the change in proportion of refusal increasing from 15% (n=23) in 2016 quarter three to 47% (n=110) in 2018 quarter two. In this geographic area, combined refused/transported EMS heroin overdoses compared to traditional ED data demonstrates opposing heroin overdose patterns for the same local with EMS showing and increasing trend overtime and ED showing a decreasing trend (Fig 3).ConclusionsTraditional public health surveillance for heroin overdose has historically relied on ED billing data, though agencies are starting to use syndromic surveillance, too (Vivolo-Kantor et al., 2016). These systems share similar underlying ED data, albeit with different components, quality, and limitations. However, in terms of the overdose epidemic, both are limited to only heroin overdoses that result in ED hospital encounters. The recent drastic increase in refused transport can have significant impacts on heroin surveillance. Jurisdictions relying on SyS or ED data for monitoring overdose patterns and/or evaluating interventions may be significantly underestimating acute overdose occurrence in the population. This analysis highlights the importance of this preclinical data source in surveillance of the heroin epidemic.ReferencesRock, P. J., & Singleton, M. D. (2018). Assessing Definitions of Heroin Overdose in ED & EMS Data Using Hospital Billing Data, 10(1), 2579.Vivolo-Kantor, A. M., Seth, P., Gladden, ; R Matthew, Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2016). Morbidity and Mortality Weekly Report Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, 67(9), 279–285. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6709e1-H.pdf

INTRODUCTIONCo-morbid post-traumatic stress disorder (PTSD) and low back pain (LBP) are common reasons for increased disability in the Veteran communities. Medical discharge from the military represents a considerable financial cost to society. Little is currently known about the impact of LBP and PTSD as longitudinal risk factors for medical discharge from Active Duty military service.MATERIALS AND METHODSA retrospective analysis of US Army Active Duty Soldiers from 2002 to 2012 was performed to determine the risk for medical discharge. Four levels of exposure for were identified as independent variables: no chronic LBP or PTSD, chronic LBP only, PTSD only, and co-morbid PTSD present with chronic LBP. Statistical analysis utilized modified Poisson regression controlling for sex, age, rank, time in service, deployment, mental health, sleep disorders, alcohol use, tobacco use, obesity, and military occupation. This study was approved by a Department of Defense Institutional Review Board.RESULTSAfter controlling for potential confounding variables, the RR for chronic LBP and PTSD independently was 3.65 (95% CI: 3.59-3.72) and 3.64 (95% CI: 3.53-3.75), respectively, and 5.17 (95% CI: 5.01-5.33) when both were present.CONCLUSIONSThis is the first study to identify a history of both chronic LBP and PTSD as substantial risk factors for medical discharge from the US Army. PTSD and chronic LBP may mutually reinforce one another and deplete active coping strategies, making Soldiers less likely to be able to continue military service. Future research should target therapies for co-morbid PTSD and chronic LBP as these conditions contribute a substantial increase in risk of medical discharge from the US Army.

BACKGROUND:Surveillance of youth suicide attempts presents many challenges. To assess common data sources that capture information about youth suicidal behavior, we compared counts of high school students who reported (a) a suicide attempt and (b) an injurious suicide attempt, requiring medical treatment in the previous twelve months, with counts of suicide deaths and intentional self-injuries obtained from administrative data sources.METHOD:Youth Risk Behavior Surveillance System (YRBSS), high school enrollments, and vital statistics were used to estimate the ratio of suicide attempts to suicide deaths among Kentucky high school students. YRBSS and enrollment data were used to estimate the number of Kentucky high school students who received medical treatment following a suicide attempt, which was compared with hospital and emergency department (ED) discharges for intentional self-injury from administrative claim records.RESULTS:We estimated 943 students reporting a suicide attempt for every suicide death, a result that is higher than previous estimates for youth. Self-reported suicide attempts resulting in medical treatment were 7.5 times higher than self-injuries reported in claims records.CONCLUSION:Future research should address concerns about undocumented cases of intentional self-injury in administrative claims systems; patient encounters in nonhospital settings for injuries resulting from a suicide attempt; and validity of Youth Risk Behavior Survey questions on suicidal behavior.

Buprenorphine/naloxone (sold as Suboxone, among other brands) is a highly effective treatment for opioid dependence [8]. As interventions to curb the opioid crisis become more prevalent, we anticipate the number of patients on buprenorphine/naloxone presenting for elective surgery to rise. Buprenorphine/naloxone therapy requires special consideration in the peri-operative period. Balancing the risks of withdrawal and relapse with the need for analgesia is crucial to good outcomes after a painful procedure. There are two main strategies for acute pain management in patients on buprenorphine/naloxone [1–3, 6, 12, 13, 15]. One option is to stop therapy temporarily approximately 72 h prior to surgery to allow drug elimination and facilitate post-operative opioid efficacy. A second option is to continue buprenorphine/naloxone therapy throughout the episode of surgical care and to use short-acting opioid receptor agonists to treat acute pain. Unfortunately, each strategy has significant disadvantages. Discontinuing buprenorphine/naloxone therapy before surgery confers a high risk of opioid withdrawal and relapse [6, 12]. Additionally, stopping therapy with the goal of treating acute pain is not always associated with better pain control [5]. Conversely, patients who continue on buprenorphine/naloxone often require higher-than-usual doses of opioids to control acute pain [4, 5, 15]. In addition to suboptimal analgesia, the high opioid requirement increases the risk of opioid-related adverse effects, particularly respiratory depression. Indeed, recommendations for extended monitoring have been made on the basis of patient safety (up to 72 h in one case report) [6]. To date, there are no reports demonstrating whether and how buprenorphine/naloxone can be continued through the peri-operative period, while achieving optimal analgesia and minimizing patient risk. Clinical and institutional guidelines for surgical patients on buprenorphine/naloxone typically include a recommendation to maximize regional anesthesia and analgesia [6, 9, 13]. Despite this, no publications have described the role of peripheral nerve block (PNB) or peripheral nerve catheter (PNC) in surgical patients maintained on buprenorphine/naloxone therapy. Here, we report the first such case. We made use of a PNC and provided multidisciplinary care to allow uninterrupted buprenorphine/naloxone therapy in a patient undergoing a painful orthopedic procedure: arthroscopic repair of a large rotator cuff tear.

To the e ditor , We write to advocate for the inclusion of supplementary video content as a routine part of any submissions to Regional Anesthesia and Pain Medicine ( RAPM ) that involve a procedure. Numerous studies provide descriptions of an associated block technique, typically in the form of

Objective: The aim of this project was to develop a nimble system to both monitor and report on the quality of Kentucky emergency department syndromic surveillance (SyS) data at system-wide and facility levels.Introduction: In 2016, the CDC funded 12 states, under the Enhanced State Opioid Overdose Surveillance (ESOOS) program, to utilize SyS to increase timeliness of state data on drug overdose events. In order to operationalize the objectives of the grant, there was a need to assess and monitor the quality of Kentucky’s SyS data, with limited resources. We leveraged the NSSP’s R Studio Server to automate quality assurance (QA) monitoring and reporting to meet these objectives.Methods: Using the R Server, we pulled data from the process messages table, aggregating messages to single patient encounters. In addition to compiling the code on a powerful remote server, the server can access the process table messages relatively quickly. We developed an R Markdown report to produce a report that includes a variety of system- and facility-level metrics that highlight key indicators of system performance and data flows. By using R, we were able to create an auto-generating QA report that runs weekly and e-mails for analyst review. Quality metrics included: % completeness of chief complaint and discharge diagnosis codes (overall and by facility)[Fig 1 & Fig 2]; visit trend by day of visit (with interactive spark lines)[Fig 2]; maximum date of message created, date message arrived at NSSP server, date of visit, and total messages[Fig 3]; message arrived trend (interactive sparklines)[Fig 3]; volume and type of error messages failing to process[Fig 4]; message volume by ADT type[Fig 5]; and volume of patient class by type by day[not shown]. Our SyS analyst reviews the report and delivers it to stakeholders with general comments about ongoing and newly emerging data quality concerns.Results: The report has proven to be beneficial in ongoing QA monitoring. The report is shared weekly with key stakeholders at the Kentucky Department for Public Health, Kentucky Health Information Exchange, NSSP, and regional ESSENCE users. Findings are reviewed at monthly SyS stakeholder meetings. The report has identified numerous errors, dead feeds, and other systems changes in near real-time; leading to corrective action and general data quality enhancement. Weekly monitoring of QA has improved data feed stability and communication of identified issue with key stakeholders.Conclusions: The R Studio Server provides a nimble platform to develop, refine, and automate a QA reporting system that can lead to improved SyS data quality. In Kentucky, in addition to improving overall data quality, these weekly reports and subsequent communication have help built relationships among key stakeholders and elevated the importance of syndromic surveillance data locally. Continual monitoring of data is critical to ensure quality and therefor the validity of the data.

It has long been stated that six people are left behind following every suicide. Despite a lack of empirical evidence, this has been extensively cited for over 30 years. Using data from a random-digit dial survey, a more accurate number of people exposed to each suicide is calculated. A sample of 1,736 adults included 812 lifetime suicide-exposed respondents who reported age and number of exposures. Each suicide resulted in 135 people exposed (knew the person). Each suicide affects a large circle of people, who may be in need of clinician services or support following exposure.