UPMC Hamot

OBJECTIVE Sublingual (SL) buprenorphine is a cornerstone of care in the treatment of adult opioid use disorder. Recent studies have demonstrated its advantages in the management of neonatal opioid withdrawal syndrome (NOWS). Commercially available SL tablets and transdermal patches are not amenable to neonatal use, and published compounding formulas of SL solutions contained undesirable excipients, including ethanol, sugars, and preservatives. The objective of this research is to explore the stability of a novel SL buprenorphine formulation free of alcohol, sugars, and preservatives. METHODS A 0.075 mg/mL buprenorphine solution was prepared by diluting the commercial injectable solution with normal saline and packaged into polyethylene terephthalate amber prescription bottles and polypropylene amber oral syringes and stored in refrigeration. Quality assessments were conducted by visual, pH, and high-performance liquid chromatography (HPLC) analysis immediately after preparation, and at 7 and 14 days of storage. RESULTS There were neither visual nor pH changes detected through 14 days. HPLC analysis indicated that all samples retained >99% initial buprenorphine concentration. Drug concentration increased slightly in the oral syringe after day 7, probably due to moisture loss. No degradation peaks were observed in chromatograms. CONCLUSIONS This novel buprenorphine is free of alcohol, sugar, and preservatives, and it may offer a significant safety advantage for NOWS patients. Additional clinical studies are recommended to verify the bioavailability and efficacy of this formulation.

Background:Although multiple primary melanomas (MPMs) have been reported in the literature, the subgroup of synchronous melanomas (SMs) remains understudied.Methods:We conducted a comprehensive systematic review of the English literature from 1972 to 2023 to characterize SM. Our objective was to clarify the definition, determine incidence and prognosis, and present recommendations.Results:We found 18 case series articles and six case reports that met our criteria. Twelve of eighteen studies defined SM as a second primary melanoma identified within 1 month. The total number of SM patients reported was 1083. The cumulative percentage of MPM in total melanoma patients was 2.9 %, and the cumulative percentage of SM patients in MPM patients was 31.3%. SM patients trended toward higher body anatomical concordance, older age, and male sex. Despite limited data, SMs do not show a worse prognosis for patients compared with single melanomas.Conclusions:Despite a lack of consensus in the past, we recommend that SM be defined as a second primary melanoma detected within 1 month of the initial diagnosis. SMs comprise almost one-third of MPM cases and do not seem to carry any worse prognosis than the patients presenting with single melanoma. We believe older age and male sex may be more prone to SM. We recommend patient education, self-skin evaluations and TSE at initial and follow-up visits. Neither randomized controlled trials nor meta-analyses on SM exist. Ideally, further studies with a large cohort of patients are needed to accurately define SM.

The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system. We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways. The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home. Surgical airways are an infrequently performed procedure in the rural prehospital setting.There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.

Cases: This study compares 2 cases of 4-part proximal humerus fracture-dislocations managed by reverse total shoulder arthroplasty: one with significant medialization and acute surgical management and another with mild medialization and delayed surgical management. Both presented with normal vascular examination; however, computed tomography angiography (CTA) revealed vascular involvement necessitating thoracic or vascular surgery consultation. Conclusion: Although vascular injuries are rare, they should be considered in patients with complex injuries, particularly those with delayed treatment or medialization of a bony structure. Our cases highlight important fracture characteristics where a preoperative CTA should be considered even with a normal vascular examination.

Background:Timely diagnosis of structural heart disease improves patient outcomes, yet many remain underdiagnosed. While population screening with echocardiography is impractical, ECG-based prediction models can help target high-risk patients. We developed a novel ECG-based machine learning approach to predict multiple structural heart conditions, hypothesizing that a composite model would yield higher prevalence and positive predictive values to facilitate meaningful recommendations for echocardiography.Methods:Using 2 232 130 ECGs linked to electronic health records and echocardiography reports from 484 765 adults between 1984 to 2021, we trained machine learning models to predict the presence or absence of any of 7 echocardiography-confirmed diseases within 1 year. This composite label included the following: moderate or severe valvular disease (aortic/mitral stenosis or regurgitation, tricuspid regurgitation), reduced ejection fraction <50%, or interventricular septal thickness >15 mm. We tested various combinations of input features (demographics, laboratory values, structured ECG data, ECG traces) and evaluated model performance using 5-fold cross-validation, multisite validation trained on 1 site and tested on 10 independent sites, and simulated retrospective deployment trained on pre-2010 data and deployed in 2010.Results:Our composite rECHOmmend model used age, sex, and ECG traces and had a 0.91 area under the receiver operating characteristic curve and a 42% positive predictive value at 90% sensitivity, with a composite label prevalence of 17.9%. Individual disease models had area under the receiver operating characteristic curves from 0.86 to 0.93 and lower positive predictive values from 1% to 31%. Area under the receiver operating characteristic curves for models using different input features ranged from 0.80 to 0.93, increasing with additional features. Multisite validation showed similar results to cross-validation, with an aggregate area under the receiver operating characteristic curve of 0.91 across our independent test set of 10 clinical sites after training on a separate site. Our simulated retrospective deployment showed that for ECGs acquired in patients without preexisting structural heart disease in the year 2010, 11% were classified as high risk and 41% (4.5% of total patients) developed true echocardiography-confirmed disease within 1 year.Conclusions:An ECG-based machine learning model using a composite end point can identify a high-risk population for having undiagnosed, clinically significant structural heart disease while outperforming single-disease models and improving practical utility with higher positive predictive values. This approach can facilitate targeted screening with echocardiography to improve underdiagnosis of structural heart disease.

Perimenopause is a time in a woman's life where fertility may vary depending upon her age and her reproductive stage and has been defined as the transition period prior to menopause that is characterized by irregular menses, hormonal changes, vasomotor symptoms, and declining fertility (Casper, 2020). Fertility tracking during this time in a woman's reproductive stage has not been widely studied. Employing the use of Luteinizing Hormone Urine Assay sticks, an electronic hormonal monitor device or mucus, we propose a set of guidelines to determine the potentially fertile times of a woman's cycle based on staging according to the Stages of Reproductive Aging Workshop (STRAW) criteria and illustrate their application with three case reports.

Background This study evaluates the stiffness of both 4.5 mm dynamic compression plates (DCP) and 3.5 mm hybrid locking-compression plates (LCP) for treatment of humeral shaft fractures in a simulated weight bearing model. Methods Testing was performed on 16 4th generation Sawbones humeri. Initial axial and torsional stiffness were determined. Plates were placed and a 5 mm defect was produced. Specimens were subjected to 90,000 loading cycles to simulate 90 days of crutch walking and then loaded to failure. Statistical analysis was performed using a t-test with significance at P &lt; 0.05. Findings Comparison reveals a significant difference between the intact axial and torsional stiffness of 4.5 mm DCPs and 3.5 mm LCPs. The 3.5 mm plates provided 80% of the axial stiffness and 75% of the torsional stiffness of the 4.5 mm plates. The 3.5 mm plated bones failed at 79% of the mean failure load of the 4.5 mm plated bones. The 3.5 mm plated bones failed due to incidental torsion during axial loading; the 4.5 mm plated bones failed as a result of gap closure. Interpretation Our results followed expectations due to differences in plate dimensions. There were no apparent differences between constructs following cyclic loading. Our model includes a fracture gap, which requires the plate to carry the entire load. This does not simulate the actual clinical scenario wherein healing would tend to improve construct performance. While the constructs performed differently, both appear to support loads that are anticipated in the clinical setting.