Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Individuals who engage in illicit or nonmedical opioid use may have elevated risk of health and social consequences, including progression to opioid use disorder (OUD). Preventive interventions to reduce this risk are lacking. This trial tested the impact of a primary care-integrated collaborative care approach for reducing risky opioid use, defined as nonmedical use of prescription opioids or any use of illicit opioids. DESIGN/METHODS:Cluster-randomized controlled trial randomized primary care providers (PCPs) and their patients into the Subthreshold Opioid Use Disorder Prevention (STOP) intervention or enhanced usual care (EUC). SETTING/METHODS:Primary care clinics at 5 U.S. sites. PARTICIPANTS/METHODS:PCPs and their patients were recruited January 2021-May 2023. A total of 119 PCP clusters (STOP = 48, EUC = 51) and 202 patients (STOP = 88, EUC = 114) enrolled. Eligible patients were adults (≥18 years) having current risky opioid use, without moderate-severe OUD. Patient participants were majority female (63.4%), white (70.8%) and non-Hispanic (96.5%), with a mean age of 55.7 [standard deviation (SD) = 12.7] years. At baseline, 63.4% of participants had moderate-severe pain (Brief Pain Inventory) and below average physical (79.2%) and mental (62.4%) health (SF-12). INTERVENTIONS/METHODS:The STOP collaborative care intervention consisted of brief advice from the PCP about reducing risky opioid use, meetings with a clinic-embedded nurse care manager over 12 months and remote health coaching (2-6 sessions). Both groups received primary care treatment as usual and overdose risk reduction materials. MEASUREMENTS/METHODS:The primary outcome was total days of risky opioid use, recorded from 6 monthly electronic surveys. A key secondary outcome was moderate-severe OUD at 6 and 12 months. FINDINGS/RESULTS:A total of 77 (87.5%) STOP and 107 (93.9%) EUC participants completed the 6-month assessment period. The primary outcome analysis used the Intention-to-Treat sample with multiple imputations of missing data. Mean days of risky opioid use at 180 days were lower in STOP than EUC [12.2 (SD = 27.73) vs. 15.5 (SD = 32.64)]; the difference between groups adjusted for baseline risky opioid use was not statistically significant (rate ratio 0.95, 95% confidence interval = 0.52-1.74). One STOP participant (1.1%) and 13 EUC participants (11.4%) developed moderate-severe OUD at 6 months, and 3 (3.4%) STOP and 6 (5.3%) EUC participants had moderate-severe OUD at 12 months (P < 0.001). CONCLUSIONS:This cluster-randomized controlled trial did not find evidence that the STOP intervention for reducing risky opioid use produced greater reductions over 6 months compared with enhanced usual care, though fewer intervention participants progressed to moderate-severe opioid use disorder. Patients had a high burden of pain and comorbidities that may present challenges to reducing opioid use.

BACKGROUND:Understanding the research experiences of bereaved parents is necessary to advance palliative care. OBJECTIVE:To evaluate levels of and factors associated with bereaved parent comfort, benefit, and distress from research participation and to qualitatively explore research experiences. STUDY DESIGN/METHODS:Exploratory analysis of survey data from parents of infants who died in a level IV NICU (2010-2020). Fisher's exact and Chi-square tests were used to identify factors associated with parental comfort, distress, and benefit. Qualitative analyzed was performed using the constant comparative method. RESULTS:40/146 parents (27%) responded. 83% reported being "very comfortable" or "comfortable", 83% reported "some" to "a lot" of benefit, 26% reported "a great deal" to "a lot" of distress from participation. Goal-discordant care was significantly associated with distress. Research participation themes included "helping others", "processing experiences" and "re-living negative experiences". CONCLUSION/CONCLUSIONS:Bereaved NICU parents simultaneously experience distress, comfort, and benefit from research participation.

The loss of Royal Mail Ship (RMS) Titanic has been examined extensively through the lenses of engineering failure, maritime law, and social history, yet little attention has been paid to the conduct and professional identity of her medical officers. This surgical history examines the lives and final hours of the ship's 2 surgeons, Dr. William Francis Norman O'Loughlin and Dr. John Edward "Jack" Simpson, situating their actions within the evolving practice of maritime medicine in the early 20th century. Drawing on contemporary newspaper accounts, official inquiries, archival records, personal correspondence, and genealogical sources, this article reconstructs their careers, responsibilities, and conduct during the disaster. O'Loughlin, a senior surgeon with decades of maritime experience, and Simpson, a younger assistant surgeon at the outset of his career, represented 2 generations united by a shared professional ethic. Both remained at their posts, assisting passengers and crew, maintaining calm, and declining opportunities for self-preservation. Their actions exemplify the unwritten code of the surgeon: composure under pressure, disciplined and methodical judgment, and a steadfast respect for the dignity of every human life. Beyond documenting individual bravery, this article demonstrates that their conduct reflects enduring principles of surgical professionalism that transcend era, technology, and setting. In a tragedy remembered primarily for its scale, the surgeons' story highlights how judgment, humanity, and moral responsibility remain central to the identity of the surgeon, whether practiced in a modern operating room or a rolling hospital at sea.

BACKGROUND:Poor persistence and adherence to attention-deficit/hyperactivity disorder (ADHD) medication is a significant barrier to effective long-term care, particularly during adolescence, yet age-specific and sex-specific trajectories remain poorly characterised. OBJECTIVE:To characterise medication initiation, discontinuation and long-term adherence patterns for children and adolescents diagnosed with ADHD in a real-world setting. METHODS:A nationwide retrospective cohort study, including 8961 children and adolescents (aged <18 years) with a new ADHD diagnosis in child and adolescent mental health services between 1 January 2010 and 31 December 2012, with follow-up until 31 December 2021. Main outcomes were medication initiation rates; time to first medication discontinuation, analysed using Kaplan-Meier estimates and restricted mean survival time at 1 year and longitudinal adherence, measured by the proportion of days covered over 9 years. FINDINGS/RESULTS:Of the 8961 individuals in the cohort (mean age at diagnosis, 12 years; 69% male), 6661 (74.3%) initiated medication, with a median time from diagnosis to initiation of 106 days (IQR 17-231); 55% initiated within 90 days. Discontinuation increased significantly with age; adolescents aged 15-17 years remained on treatment for 31.9 fewer days (95% CI -40.8 to -23.1; p<0.001) in the first year compared with children aged 5-11 years. Females also discontinued significantly earlier than males (difference -13.2 days; 95% CI -19.8 to -6.5; p<0.001). Longitudinal analysis confirmed that older age at initiation and female sex were associated with a significantly steeper decline in medication coverage over time. CONCLUSIONS:Discontinuation and low adherence to ADHD medication were common and increased substantially through adolescence, with females at higher risk of early cessation. CLINICAL IMPLICATIONS/CONCLUSIONS:Late adolescence warrants closer clinical monitoring and shared decision-making to support appropriate treatment continuation or well-informed discontinuation, particularly for older adolescents and females. Integrating structured transition planning and attention to sex-specific barriers may help reduce avoidable non-adherence during this high-risk period.

IMPORTANCE/UNASSIGNED:African American and rural-dwelling family caregivers of persons with newly diagnosed advanced cancer perform critical, time-intensive tasks and historically have had limited resources to support their role. OBJECTIVE/UNASSIGNED:To determine the effect of a lay coach-led, early palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends [ENABLE] Cornerstone) for African American and rural-dwelling family caregivers of patients with advanced cancer on caregiver and patient outcomes at 24 weeks. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This single-blind randomized clinical trial was conducted from January 2020 to May 2025 at outpatient oncology clinics at 2 large cancer centers in the Southeastern US. Participants were African American and rural-dwelling family caregivers aged 21 years or older self-identifying as an unpaid close friend or family member who is involved with the day-to-day medical care of a patient with advanced cancer. INTERVENTION/UNASSIGNED:The intervention included 6 weekly, 20- to 60-minute psychosocial telephonic sessions facilitated by a trained lay coach plus monthly follow-up. Usual care consisted of mailed pamphlets outlining resources for families at each of the cancer centers. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was caregiver distress (anxiety and depressive symptoms as measured by the Hospital Anxiety and Depression Scale [HADS]) at 24 weeks. Secondary outcomes were caregiver and patient quality of life (QOL; measured with the Patient-Reported Outcomes Measurement Information System Global Health Short Form), caregiver burden (Montgomery-Borgatta Caregiver Burden Scale), and patient distress (HADS). Outcomes were assessed using baseline-constrained linear mixed-effects models. RESULTS/UNASSIGNED:A total of 222 family caregivers (mean [SD] age, 55.5 [14.7] years; 169 [76.1%] female; 114 [51.4%] African American; 101 White [45.5%]; 7 other race [3.2%]) and 165 patients (mean [SD] age, 60.7 [12.2] years; 98 [59.4%] female; 79 African American [47.9%]; 84 White [50.9%]; 2 other race [1.2%]) were randomized. At week 24, no relevant between-group differences were observed in caregiver HADS anxiety (mean [SE] baseline-adjusted difference, 0.23 [0.44]; Cohen d = 0.05; 95% CI, -0.14 to 0.24; P = .60) or HADS depressive symptom scores (mean [SE] baseline-adjusted difference, 0.04 [0.41]; Cohen d = 0.01; 95% CI, -0.19 to 0.21; P = .91). For all other outcomes, 24-week differences were of small magnitude and not statistically significant. Exploratory sensitivity analyses of caregivers distressed at baseline indicated improvements in caregiver anxiety (mean [SE] baseline-adjusted difference, -1.21 [0.53]; Cohen d = -0.38; 95% CI, -0.70 to -0.05) and patient mental health QOL (mean [SE] baseline-adjusted difference, 3.00 [1.37]; Cohen d = 0.45; 95% CI, 0.04 to 0.86), but no statistically significant differences in caregiver burden (mean [SE] baseline-adjusted difference, -1.15 [0.69]; Cohen d = -0.32; 95% CI, -0.71 to 0.06) and patient depression (mean [SE] baseline-adjusted difference, -1.30 [0.71]; Cohen d = -0.37; 95% CI, -0.77 to 0.03). CONCLUSIONS/UNASSIGNED:This randomized clinical trial of a telehealth intervention for African American and rural-dwelling caregivers of patients with advanced cancer found no differences in caregiver and patient outcomes at 24 weeks. However, an exploratory sensitivity analysis indicated potential improvements in caregiver anxiety and patient mental health QOL. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04318886.

INTRODUCTION/BACKGROUND:Contemporary abdominal wall reconstruction places a strong emphasis on optimizing extraperitoneal mesh placement. When the posterior layer is insufficient for closure, adjuncts such as hernia sac, omentum, or Vicryl mesh have been described. The outcomes of various posterior layer supplementation (PLS) materials, both autologous and non-autologous, have not been well examined. We aim to evaluate the outcomes of patients undergoing ventral hernia repair with extraperitoneal mesh placement who undergo PLS and compare how PLS materials impact these outcomes. METHODS:All patients who underwent a retromuscular hernia (RM) repair with PLS between Jan 2021 and Jan 2025 at a single center were reviewed. Patient demographics, preoperative characteristics, intraoperative factors, and postoperative outcomes were evaluated. Descriptive statistics and comparative tests including Mann-Whitney U test, Student's t-test, and Fisher's exact test were utilized. RESULTS:Sixty-seven patients underwent RM repair with PLS. Supplement materials used included hernia sac, omentum, falciform ligament, prior mesh, new biologic, and biosynthetic coated mesh. Fifty-two percent (n = 35) of the repairs were retrorectus only and 48% (n = 32) were transversus abdominus releases. The average length of follow-up was 189 days with a recurrence rate of 3%. Sixty percent of PLS was performed with autologous material with 40% utilizing new biologic or biosynthetic coated meshes. SSI, SSO, and SSOPI were similar between the autologous and non-autologous supplementation groups (p = 1, p = 0.16, p = 0.29, respectively). There were more postoperative bowel obstructions in the non-autologous group (n = 4) as compared to the autologous group (n = 0) (p = 0.02). All the bowel obstructions were managed nonoperatively. DISCUSSION/CONCLUSIONS:Our findings suggest that outcomes are acceptable with minimal morbidity when comparing autologous tissue to biologic and biosynthetic coated mesh for PLS. The low recurrence rates observed, regardless of the material used, support the continued adoption of this approach. Proactive supplementation of the visceral sac may decrease need for lateral myofascial release.