Joint Interventions Research Articles

Operationalizing a community-based One Health surveillance and response in Adadle district of Ethiopia

Abstract Surveillance of human and animal health is often carried out separately worldwide, which leads to the under-reporting of zoonotic and emerging diseases. Early cross-information between wildlife, domestic animal and public health sectors may reduce both exposure and cost of outbreaks. We have assessed the feasibility of a One Health Surveillance and Response System (OHSRS) in the Adadle district of Ethiopia in the Somali Region (SRS), with regard to integration into the existing regional surveillance-response system in the Somali Region of Ethiopia (SRS). To meet the objectives of a surveillance-response system, we established a One Health Surveillance and Response Unit (OHSRU) at the district level. Community Animal Health Workers, Community Health Workers (CHWs), and both human and animal health district staff and regional experts were trained together on the OHSRS. An inception workshop was held with all relevant stakeholders. To ensure the active engagement of communities in the surveillance response system, a Community-Based Emergency Fund (CBEF) and CAHW cost recovery mechanisms were established. All public and animal health staff of different administration levels were linked together. Human and animal health information was collected and shared effectively among sectors. This approach helped bridging the physical separation between the public and animal health sectors in disease surveillance in the Adadle district. Joint interventions, such as disease outbreak investigations and community awareness were initiated by the OHSRU. We demonstrated that the OHSR was successfully operationalized in Adadle districts and contributed to improving the early detection and response of zoonotic diseases. However, technical barriers, cost-effectiveness, legality of data and ethical safeguarding, along with political commitment should be addressed to effectively operationalize the OHSR in the whole region. Designing the OHSR through the existing surveillance system, engaging communities and other relevant sectors using a participatory process is an important contribution to a sustainable OHSR. One Health Impact Statement In this research work, the public and animal health sectors collaborated in data collection and initiated joint interventions. By integrating the surveillance operational costs for disease outbreak investigation and cost of public health associated with zoonotic diseases can be reduced as One Health surveillance and response lead to early detection and response to zoonotic diseases. As one health is collaborative efforts multispectral, multidisciplinary and transdisciplinary, i.e. involvement of all relevant sectors including community members and different disciplines in the launching workshop of surveillance system helped to define and agree the role of each sectors or partner’s in the One Health approach. This played a curtail role in the success of the approach. Lessons learned from this work can be used for further improvement in One Health approach in different settings.

Current Trends in the Technical Performance of Lumbar Zygapophysial Joint Interventions

Current Trends in the Technical Performance of Lumbar Zygapophysial Joint Interventions

Simulation-Based Assessment of Cholera Epidemic Response: A Case Study of Al-Hudaydah, Yemen

Cholera kills between 21,000 and 143,000 people globally each year. It is often fatal, killing up to 50% of the severely symptomatic patients; but death by cholera is preventable with timely treatment, so that the fatality rate can drop to less than 1%. Due to cholera’s multi-pathway transmission, a multifaceted and multi-sectoral approach to combat this disease is needed. Such complexity gives rise to uncertainty about where it is best to intervene, as stakeholders have to balance prevention and treatment under highly constrained resources. Using Al-Hudaydah, Yemen as a case study, this paper demonstrates how a system dynamics model can be built using a classic infection structure with empirically grounded operational structures: health treatment, water, sanitation, and hygiene (WASH), vaccination, and a data surveillance system. The model explores the implications of the joint interventions with different start times. The model analysis revealed that the historical interventions likely prevented 55% more deaths in 2017 as compared to a counterfactual business-as-usual scenario with no interventions in the past. At the same time, some 40% of deaths could potentially have been prevented if interventions (with the same resources as historical data) had been initiated earlier in April 2017. Further research will explore each intervention impact for more detailed policy analysis and simulations into the future.

Current trends in the technical performance of lumbar zygapophyseal joint interventions

ObjectiveTo survey how interventional pain physicians are currently performing lumbar facet interventions, with an emphasis on fellowship training. DesignSurvey Study. MethodsAn online electronic survey disseminated via Research Electronic Data Capture (REDCap) software to current and expired attending physician members of the Spine Intervention Society (SIS). Responses were stratified by fellowship training type: ACGME Pain Medicine (APM), ACGME Sports Medicine (ASM), Interventional Spine and Musculoskeletal Medicine (ISMM), or None. ResultsAs a whole, a majority of respondents indicated on independent questions they require 2 diagnostic medial branch blocks (MBBs) performed with 0.5 ​cc or less of anesthetic to result in at least 75% pain relief before proceeding with a radiofrequency neurotomy (RFN), performed via parallel approach with 18g or larger needle and 10 ​mm active tip and a lesion of at least 80–85° C and 90–119 ​s of duration. Statistically significant differences as stratified by APM vs ISMM fellowship training included: the use of corticosteroids at the time of RFN (43/79 (54.4%) vs 16/63 (25.4%), typically treating 3 segments or more 22/79 (27.8%) vs 7/73 (9.6%), and MBB volume injectate of ≥ 1 ​cc 22/79 (27.8%) vs 7/63 (11.1%) respectively. ConclusionsThere is largely agreement upon the technical performance of lumbar facet interventions by members of SIS. Physicians who completed an APM fellowship were more likely to report using corticosteroids at the time of RFN, using higher anesthetic volumes and treating 3 or more spinal segments.

Facets of facet joint interventions.

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

S1369 Outcomes of Gout in Patients With Cirrhosis - A NIS-Based Study

Introduction: Hyperuricemia is a prerequisite for the development of gout. Elevated serum uric acid (UA) levels result from either overproduction or decreased excretion (whether by the kidneys or bowel). Some literary works denote a positive correlation between serum UA levels, cirrhosis-related complications and the incidence of non-alcoholic fatty liver disease. The exact relationship, whether hyperuricemia results in worsening cirrhosis outcomes or vice versa, is unknown. Despite these correlations, few studies explore the relationship between cirrhosis and gout. We aim to explore a possible link between them. Methods: The National Inpatient Sample (NIS) was used to identify patients hospitalized with gout, stratified based on a history of cirrhosis, from 2001 to 2013 via the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. Primary outcomes consisted of mortality, gout complications (rates of flare, tophi formation, nephrolithiasis, nephropathy, and septic arthritis), and joint interventions (arthrocentesis and joint injection). Chi-squared and independent t-tests were done to assess categorical and continuous data, respectively. Multiple logistic regression was used to control for confounders, including age, sex at birth, race, cardiac arrhythmias, chronic pulmonary disease, heart failure, diabetes, HIV, HTN, peripheral vascular disease, alcohol use disorder and renal failure. Results: Patients without cirrhosis were older (70.37±13.53 years versus 66.21±12.325 years; p< 0.05). The majority of both groups were male, but cirrhotic patients had more males versus females (74.63% versus 66.83%; adjusted p=0.121). Cirrhotic patients had higher rates of mortality (5.49% versus 2.03%; adjusted p< 0.05), gout flare (2.89% versus 2.77%; adjusted p< 0.05) and tophi (0.97% versus 0.75%; adjusted p=0.677). Non-cirrhotic patients had higher rates of arthrocentesis (2.45% versus 2.21%; adjusted p< 0.05) and joint injections (0.72% versus 0.52%; adjusted p< 0.05). Rates of septic arthritis, nephropathy and uric acid nephrolithiasis did not differ significantly among both groups. Conclusion: Cirrhotics had greater incidence of gout-related complications, representing a possible link between cirrhosis and elevated average serum UA levels. Non-cirrhotics had higher rates of more invasive interventions, which could be due to clinician hesitancy with performing these interventions given increased bleeding risk in the setting of cirrhosis-related coagulopathy. (Table) Table 1. - Patient Characteristics and Differences in Inpatient Gout Outcomes in Individuals With and Without Cirrhosis Non-Cirrhotics Cirrhotics OR CI p-value AOR ACI Adjusted p-value Percentage n Percentage n Sex at birth Female 33.17 494,890 25.37 9,372 0.685 0.669-0.701 < 0.05 0.979 0.953-1.006 0.121 Male 66.83 996,939 74.63 27,576 Mortality 2.03 30,286 5.49 2,029 2.804 2.678-2.937 < 0.05 3.092 2.939-3.252 < 0.05 Gout Flare 2.77 41,282 2.89 1,066 1.044 0.982-1.11 0.171 0.816 0.765-0.871 < 0.05 Tophi 0.75 11,202 0.97 358 1.293 1.164-1.438 < 0.05 1.025 0.914-1.149 0.677 Uric Acid Nephrolithiasis 0.02 374 0.02 9 0.972 0.502-1.882 0.932 1.037 0.53-2.03 0.915 Nephropathy 0.02 283 0.01 5 0.713 0.295-1.727 0.452 0.548 0.223-1.346 0.19 Arthrocentesis 2.45 36,611 2.21 818 0.9 0.839-0.965 < 0.05 0.741 0.686-0.8 < 0.05 Joint Injection 0.72 10,673 0.52 192 0.725 0.628-0.837 < 0.05 0.713 0.61-0.833 < 0.05 Septic Arthritis 0.31 4,637 0.31 114 0.993 0.824-1.196 0.939 0.997 0.821-1.211 0.977 Mean SD SE Mean Mean SD SE Mean Mean difference CI p-value Age at admission (years) 70.37 13.53 0.011 66.21 12.325 0.064 4.167±0.071 4.027-4.306 < 0.05 n: sample size; OR: odds ratio; CI: 95% confidence interval; AOR: adjusted odds ratio; ACI: adjusted 95% confidence interval; SD: standard deviation; SE: standard error.

IRX2 activated by jumonji domain-containing protein 2A is crucial for cardiac hypertrophy and dysfunction in response to the hypertrophic stimuli

BackgroundIroquois homeobox 2 (IRX2) is a member of the Iroquois family whose upregulation has been potentially correlated to cardiac hypertrophy. This work studied the function of IRX2 and its related molecules in hypertrophic cardiomyopathy (HCM). MethodsA GEO dataset GSE32453 was analyzed to identify aberrantly expressed genes in HCM. Altered expression of IRX2 was induced in mice by lentivirus injection, followed by angiotensin II (Ang II) treatment to induce HCM. The function of IRX2 knockdown in ventricular dysfunction, heart volume and pathological changes in mice, and in surface area, oxidative stress and apoptosis of isolated cardiomyocytes were examined. Binding relationship between jumonji domain-containing protein 2A (JMJD2A) and IRX2 was predicted by online tools and validated. The interaction between JMJD2A and IRX2 in HCM development was examined by joint interventions. ResultsIRX2 was highly expressed in heart tissues with HCM. IRX2 knockdown prevented mice from Ang II-induced ventricular dysfunction, cardiac hypertrophy, inflammation and fibrosis in mouse heart, and it decreased the levels of cardiac hypertrophy-related markers, oxidative stress response, and apoptosis of Ang II-treated cardiomyocytes. JMJD2A catalyzed demethylation of H3K9me3 near the IRX2 promoter to activate its transcription. JMJD2A knockdown similarly exerted protective functions against cardiac hypertrophy in vivo and in vitro, but the protection was blocked upon further IRX2 upregulation. IRX2 was found to increase the Wnt/β-catenin signaling activation. ConclusionThis work reports that JMJD2A activates IRX2 transcription and the Wnt/β-catenin signaling to induce cardiac hypertrophy and dysfunction in HCM.

Ultrasound-guided joint interventions of the lower extremity.

The purpose of this article is to better understand the role ultrasound plays in lower extremity joint interventions. Ultrasound is an important and reliable tool diagnostically and therapeutically. Real-time feedback, lack of ionizing radiation, and dynamic maneuverability make ultrasound an important tool in the proceduralist's armament. This article will touch upon the important anatomic considerations, clinical indications, and technical step-by-step details for lower extremity ultrasound interventions. Specifically, we will look at interventions involving the hip, knee, ankle, and foot. In addition, this article will discuss the roles corticosteroid and platelet-rich plasma may play in certain interventions.

Joint interventions in osteoarthritis.

Osteoarthritis (OA) is among the most common diseases affecting both axial and appendicular joints and the lead cause of disability worldwide. OA incidence is rising due to extended life expectancy and the increasing obesity epidemic. Several joint interventions are available to manage pain and joint function in patients with OA, most of these treatments being widely applied using intra-articular injections. In this chapter, we will describe the different joint interventions available for the management of pain in OA focusing on intra-articular injections, including discussion on the evidence regarding the efficacy of these treatments, based on the most recent systematic reviews and meta-analyses available. We also discuss the importance of imaging in guiding these treatments, including the different imaging modalities available for intra-articular injection guidance, their advantages, and disadvantages. Finally, we briefly discuss safety data and the consensus regarding the most used intra-articular treatments to manage pain in OA.

The Influence of Alcohol Consumption on Tobacco Use among Urban Older Adults: Evidence from Western China in 2017

Background: Tobacco use is a global public health concern due to its association with a myriad of health hazards and costs. Previous studies have found that the disinhibiting influence of alcohol consumption may lead to an increase in tobacco use. In this study, we investigated why alcohol consumption is associated with tobacco use among older adults in Western China, and we attempted to explain the mechanisms that underlie the link between alcohol consumption and tobacco use. Methods: In this cross-sectional study, we employed a representative sample of 812 urban individuals aged 60 and older in 2017 in Western China. Results: We found that alcohol consumption (OR = 2.816, 95%CI: 1.770–4.479) was positively associated with tobacco use. Additionally, other factors, including gender (OR = 0.023, 95%CI: 0.009–0.060), age (OR = 0.758, 95%CI: 0.634–0.906), health literacy (OR = 0.977, 95%CI: 0.959–0.995) and functional impairment (OR = 0.871, 95%CI: 0.767–0.988) were also strongly related to tobacco use. Conclusions: Consistent with the results of existing studies, our findings demonstrated the disinhibiting influence of alcohol consumption on tobacco use, which confirmed the theoretical mechanisms that underlie the alcohol–tobacco link and implied the co-occurrence and co-use of alcohol and tobacco, which are used as “social lubricants” in the Chinese context. The importance of other factors related to tobacco use were also discussed. As the tobacco epidemic is combatted, joint interventions tailored to concurrent control over alcohol and tobacco need to be performed, and corresponding male-specific and age-specific health education and the reinforcement of health literacy must be considered as important priorities.

Cardiovascular risk factors and breast cancer incidence in a large middle-aged cohort study

BackgroundSeveral studies have demonstrated that cardiovascular risk factors play a role in the etiology of breast cancer. However, the combined effect of cardiovascular risk factors on the risk of breast cancer is still uncertain.MethodsData from the Atherosclerosis Risk in Communities (ARIC) study, a prospective cohort of middle-aged women, were used to investigate the association of individual and combined cardiovascular risk factors with breast cancer. Cox proportional hazards models were applied to calculate the hazard ratio (HR) and 95% confidence intervals (CI).ResultsA total of 7501 women were included. During a mean follow-up of 19.7 years, 576 women were diagnosed with breast cancer. White women and premenopausal status were independently associated with increased risk of breast cancer. Of the individual cardiovascular risk factors, only obesity was independently associated with an increased risk of breast cancer (HR 1.29, 95% CI 1.04–1.61). Compared with women without cardiovascular risk factors, women having three or greater, but not those with fewer than three cardiovascular risk factors, had a significantly higher risk of developing breast cancer (HR 1.27, 95% CI 1.06–1.53). Subgroup analyses indicated that women with three or greater cardiovascular risk factors had higher risk of breast cancer among postmenopausal Black women, but not among premenopausal Black and White women.ConclusionsCombinations of cardiovascular risk factors are associated with increased risk of breast cancer in middle-aged women, especially in postmenopausal Black women. Joint interventions to modify cardiovascular risk factors could be used to prevent breast cancer in these higher-risk individuals.

Invited Commentary: Conducting and Emulating Trials to Study Effects of Social Interventions.

All else being equal, if we had 1 causal effect we wished to estimate, we would conduct a randomized trial with a protocol that mapped onto that causal question, or we would attempt to emulate that target trial with observational data. However, studying the social determinants of health often means there are not just 1 but several causal contrasts of simultaneous interest and importance, and each of these related but distinct causal questions may have varying degrees of feasibility in conducting trials. With this in mind, we discuss challenges and opportunities that arise when conducting and emulating such trials. We describe designing trials with the simultaneous goals of estimating the intention-to-treat effect, the per-protocol effect, effects of alternative protocols or joint interventions, effects within subgroups, and effects under interference, and we describe ways to make the most of all feasible randomized trials and emulated trials using observational data. Our comments are grounded in the study results of Courtin et al. (Am J Epidemiol. 2022;191(8):1444–1452).

The lived experience of health sciences students’ participation in an interprofessional community-based stroke class

Background. Collaborative approaches in healthcare contexts may provide better care for patients. Interprofessional circuit-based group therapy could counter profession-specific tribalism. There is no evidence on interprofessional education (IPE) community-based interventions on student learning in the health professions. Objective. To explore undergraduate health sciences students’ experience of being involved in community-based interprofessional circuit-based group therapy. Methods. Semi-structured interviews were inductively analysed exploring undergraduate health sciences students’ experience of involvement in an IPE community-based stroke intervention. Results. A total of 12 final-year students participated, with representation from physiotherapy, occupational therapy and speech therapy. This IPE opportunity beneficially impacted students’ collaborative competencies in knowledge, attitudes, skills and behaviours. This community-based rotation immersed students in a service-delivery environment where patient management was co-ordinated by a multiprofessional rehabilitation team. The integrated stroke circuit group activity aimed to enhance further interconnectedness between student participants. Students who were exposed to this clinical activity reported an understanding of (i) patients’ unique contexts; (ii) role development and complementary overlap between health professions; and (iii) the value of joint interventions to both patients and rehabilitation teams in resource-constrained settings. Conclusion. These students have been primed in their practice-readiness as healthcare professionals for the 21st century who will promote quality care, and embrace collaborative professional practice and person-centredness.

A Network Dynamics Model for the Transmission of COVID-19 in Diamond Princess and a Response to Reopen Large-Scale Public Facilities.

Background: The current epidemic of COVID-19 has become the new normal. However, the novel coronavirus is constantly mutating. In public transportation or large entertainment venues, it can spread more quickly once an infected person is introduced. This study aims to discuss whether large public facilities can be opened and operated under the current epidemic situation. Methods: The dual Barabási–Albert (DBA) model was used to build a contact network. A dynamics compartmental modeling framework was used to simulate the COVID-19 epidemic with different interventions on the Diamond Princess. Results: The effect of isolation only was minor. Regardless of the transmission rate of the virus, joint interventions can prevent 96.95% (95% CI: 96.70–97.15%) of infections. Compared with evacuating only passengers, evacuating the crew and passengers can avoid about 11.90% (95% CI: 11.83–12.06%) of infections; Conclusions: It is feasible to restore public transportation services and reopen large-scale public facilities if monitoring and testing can be in place. Evacuating all people as soon as possible is the most effective way to contain the outbreak in large-scale public facilities.

Management of joint empyema

Joint empyema, also known as septic arthritis, is asevere disease associated with considerable morbidity and mortality. Failing to initiate immediate treatment can result in irreversible joint destruction within a short time. The knee joint is most frequently involved, followed by the shoulder and hip joints. Small joints are rarely affected. Typical risk factors include immunosuppression, renal insufficiency, diabetes mellitus and previous joint interventions. An early targeted diagnostic work-up and initiation of therapeutic steps is crucial to avoid irreversible joint destruction. Joint aspiration for diagnostic purposes is essential and should be performed immediately when aseptic arthritis is suspected. An important differential diagnosis is metabolic arthritis (gout and chondrocalcinosis), which typically presents in asimilar way. Adifferentiation from septic arthritis is important as metabolic arthritis requires acompletely different treatment. After confirming the diagnosis, treatment consisting of asurgical procedure combined with antibiotics is initiated. In most cases an arthroscopic intervention is sufficient. In severe cases the arthroscopy needs to be repeated. An arthrotomy must be carried out only rarely. Apre-emptive antibiotic treatment is initially administered and is later adjusted according to the resistogram. This article gives an overview on the pathophysiology, diagnostics and general management of joint empyema.

The prioritisation of zoonoses in the Republic of North Macedonia – Do we need one health approach

Zoonoses have a different impact on public health, determined by geographical and socio-economic factors, which requires their prioritization for prevention and control purposes to be performed at the national level. Prioritization of zoonoses is a mechanism used in policy-making, primarily in allocating available resources. Aim of the paper is to compare two different methods used for prioritization of zoonoses by Institute of public health (IPH) and Food and Veterinary Agency (FVA). Material and methods: IPH used a method prepared by the U.S. Centers for Disease Control and Prevention (CDC), - One Health Zoonotic Disease Prioritization (OHZDP) tool, adapted to national conditions (2019). FVA used a standardized semi-quantitative method based on the OIE Methodological Manual (List and Categorization of priority diseases in animals including and those transmitted to humans). A total of 21 zoonoses have been selected, based on their importance for the human and veterinary sector. These diseases are ranked according to the stated criteria of the two previously conducted prioritizations and their comparison is performed. Results: With the prioritization conducted by IPH and FVA the first 5 ranked zoonoses are: Hemorrhagic fevers with renal syndrome, Leishmaniasis, Tularemia, Brucellosis and Listeriosis. With the prioritization carried out by the FVA the first 5 ranked zoonoses are: Bovine brucellosis, Bovine tuberculosis, Salmonellosis, Avian influenza and West Nile fever. A Cumulative Annual Incidence is taken as a control parameter. Regarding this, the 5 first ranked zoonoses are Echinococcosis, Brucellosis, Lyme fever, Leishmaniasis and Tularemia. Conclusions: A comparative analysis of the separate lists of priorities for human and veterinary medicine shows that only a certain percentage overlap. Also, the presence of a number of zoonoses with endemic character, but also a more pronounced risk of new emergent diseases, determines the need to provide consensus on the methodology of prioritization of zoonoses, and its formalization and institutionalization, as a crucial step towards identification and prioritization of zoonoses that would be the subject of joint programs and interventions.

59. The incidence of ischemic and hemorrhagic complications associated with ceasing vs maintaining anticoagulant and/or antiplatelet agents for spine pain interventions targeting the facet joint

<h3>BACKGROUND CONTEXT</h3> Facet joint interventions include medial branch blocks (MBB), radiofrequency ablation (RFA) and facet joint intra-articular injections (IA). Currently, American Society for Regional Anesthesia (ASRA) guidelines list these procedures as intermediate risk for the cervical and thoracic spine and low risk for lumbar spine. Accordingly, these guidelines recommend many anticoagulation (AC) medications and antiplatelet (AP) medications to be held or consideration made to hold for these procedures, presumably to mitigate the theoretical risk of a major bleeding complication. This is despite the fact there are few if any reports of serious bleeding complications that occur with these procedures, regardless of a patients AP or AC status. On the other hand, there is growing evidence suggests that the thrombotic complication risk of stopping these AC/AP medications for patients undergoing these facet joint interventions may exceed the hemorrhagic risk of maintaining them. <h3>PURPOSE</h3> The primary objective is to determine the risk of serious bleeding complications in patients undergoing facet targeted injections. The secondary objective is to determine if this is affected by the management of AC/AP medications. <h3>STUDY DESIGN/SETTING</h3> Retroscpective observational study. <h3>PATIENT SAMPLE</h3> A total of 6,598 facet joint interventions. <h3>OUTCOME MEASURES</h3> Bleeding or hemorrhagic complications within 90 days of intervention. <h3>METHODS</h3> A retrospective observational study was conducted in a private pain practice. Consecutive patients were identified between September 19, 2009 and June 16, 2017, and it was noted if they were taking AC/AP medications prior to a procedure and how these medications were managed. In patients on AC/AP medications, charts were thoroughly reviewed for thrombotic and/or hemorrhagic complications occurring within 90 days of the procedure. For all other patients not on AC/AP medications, only the rate of clinically significant hemorrhagic events were considered given there is no inherent risk of thrombosis related to facet targeted interventions. <h3>RESULTS</h3> A total of 6,598 facet joint interventions were identified. No clinically significant bleeding complications were noted noted. Of the patient sample, 581 interventions were performed on patients prescribed AC/AP medications, with only one patient was lost to follow up. In 126 of these cases, they were performed after patients ceased AC/AP medications, with no complications noted. AC/AP medications were continued in 455 cases, also with no bleeding complications noted. Interestingly, of the 581 cases three thrombotic complications were noted in the group that had maintained AC/AP medications. <h3>CONCLUSIONS</h3> In this large cohort of 6,598 cervical, thoracic, and lumbar facet targeted interventions, no cases of clinically significant bleeding complications were noted. This include no cases of clinically significant bleeding in the 581 cases in which patients were on AC/AP medications, of which 455 were continued on such medications. This suggests the overall risk of significant bleeding complications with these procedures is exceedingly low. This must be considered when managing patients on AC/AP medications, as while preventing bleeding complications is important, the risk of thrombotic complications in this patient populations may be higher. This data builds upon previous research and supports individualized perioperative risk assessment when making the decision to stop or continue AC/AP medications. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018

Spinal cord stimulation has been utilized with increasing frequency in managing chronic intractable spinal pain and complex regional pain syndrome (CRPS) in addition to other neuropathic pain states. The literature has shown the effectiveness of spinal cord stimulation in managing chronic pain with improvement in quality of life and cost utility. There have not been any reviews performed in the fee-for-service (FFS) Medicare population in reference to utilization and expenditure patterns of spinal cord stimulators. This investigation was undertaken to assess the utilization and expenditures for spinal cord stimulation in the FFS Medicare population from 2009 to 2018. The present study was designed to assess the utilization patterns and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars only trials and implants were included. Utilization patterns showed that spinal cord stimulation trials increased from 12,680 in 2009 to 36,280 in 2018, a 186% increase with an annual increase of 12.4%. The rate of trials per 100,000 population increased from 28 in 2009 to 61 in 2018 with a 120% increase, or an annual increase of 9.1%. The pulse generator implants increased from 7,640 in 2009 to 22,960 in 2018, an increase of 201%, with an annual increase of 13%. In addition, percutaneous placement with pulse generator implants increased from 4,080 in 2009 to 14,316 in 2018, a 252% increase, or 15% annual increase. In contrast, implantation of neurostimulator electrodes with paddle leads with laminectomy and placement of spinal pulse generator increased from 3,560 in 2009 to 8,600 in 2018, a 142% increase or an annual increase of 10.3%. Analysis of expenditures showed total inflation-adjusted expenditures increased from $292,153,701 in 2009 to $1,142,434,137 in 2018, a 291% increase from 2009 to 2018 and 16.4% annual increase. These expenditures were 125% higher than facet joint interventions and 138% higher than epidural interventions in 2018. In contrast, these expenditures were 55% below the expenditures of facet joint interventions and 66% lower than epidural injections in 2009.Trial to implant ratio improved from 42.5% in 2009 to 63.6% in 2018. An overwhelming majority of trials (90%) were performed by nonsurgical physicians, whereas, 56% of implants were performed by non-surgeons. This assessment includes only FFS Medicare population, thus eliminating approximately 30% of the population with Medicare Advantage plans. In addition, this study has not taken into consideration various revisions not included in 3 specific codes. The analysis of spinal cord stimulators in the FFS Medicare population from 2009 to 2018 showed explosive increases of trials, implants and overall costs.

International Cooperation Combating Financial Proceeds of Crime

The flow of illicit capital, into the financial circles of various states, is a serious threat to global security. To this end, an important part of the strategy to combat criminal proceeds is the coordination of work between states. Expanding investigative capacity across national borders is seen as an important factor in the success of the fight against crime. The exchange of information, between law enforcement agencies in different states, is one of the most effective policies for financial investigations aimed at tracking the proceeds of crime. This case, should be approciated in two aspects. On the one hand, it is necessary to adopt direct and at the same time joint interventions, to detect and monitor the movement of money or capital outside their borders. On the other hand, the conditions must be provided for an appropriate use of information and without hindering the movement of legal capital. The necessity of a common criminal policy, to deprive criminals of the proceeds of crime and the instruments for their commission, is clearly emphasized by international acts in this field. They encourage the widest possible cooperation between states for the purpose of investigating and prosecuting criminal assets.

Improving Adolescent Sexual and Reproductive Health: Can Mobile Health Interventions Affect Behavior?

* Abbreviations: LGB+ — : lesbian, gay, bisexual, and other sexual minority mHealth — : mobile health SRH — : sexual and reproductive health In this issue of Pediatrics , Ybarra et al1 report the results of a national randomized controlled trial of Girl2Girl, a mobile health (mHealth) intervention aiming to reduce pregnancy rates among lesbian, gay, bisexual, and other sexual minority (LGB+) adolescent girls. Researchers randomly assigned 948 girls aged 14 to 18 to the theory-based, user-informed text messaging intervention versus an attention-matched control group. At trial end, 5 months post-enrollment, those in the Girl2Girl intervention group were significantly more likely to have condom-protected sex and use a birth control method other than condoms. The study allows us to reflect on the overall impact of mHealth interventions to date because few mHealth interventions have been successful in affecting adolescent sexual and reproductive health (SRH) to the level of Girl2Girl.2 Several reasons likely contribute to this variation. First, behavior change is multifactorial, especially SRH behaviors, affected by a variety of societal and contextual factors. These factors make behavior change challenging to comprehensively address within one intervention. Next, retention rates in mHealth trials can be suboptimal. Adolescents frequently change phone numbers and experience phone disconnections, making patient follow-up challenging and full intervention delivery problematic.3 Lastly, the adoption of any mHealth intervention competes with a host … Address correspondence to Lauren S. Chernick, MD, MSc, Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Irving Medical Center, 3959 Broadway, CHN 1-116, New York, NY 10032. E-mail: lc2243{at}columbia.edu