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This is a case of a 56-year-old transgender female with a history of HIV who presented to the emergency department with visual disturbances and bilateral papilledema. Initially, intracranial abnormalities were ruled out through imaging studies. However, a lumbar puncture later confirmed the presence of syphilis in the cerebral spinal fluid (CSF), and the patient was diagnosed with bilateral syphilitic uveitis by a retina specialist. Treatment with intravenous and intramuscular penicillin led to significant improvement in her visual symptoms and resolution of optic nerve edema. This case underscores the importance of early screening for syphilis and other sexually transmitted infections (STIs) in transgender patients living with HIV presenting with visual symptoms. The delayed syphilis screening and treatment in this patient highlight the impact of healthcare barriers on transgender individuals. Prompt diagnosis and treatment are critical to prevent serious complications, such as permanent vision loss. Healthcare providers must maintain a high index of suspicion for syphilis in HIV-positive patients with visual symptoms, irrespective of their cluster of differentiation 4 (CD4) count or viral load. Addressing barriers to healthcare for transgender individuals is essential to ensure timely diagnosis and treatment to improve patient outcomes.

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Objective: Our study analyzed the impact of civil commitment (CC) laws for substance use disorder (SUD) on opioid overdose death rates (OODR) in the U.S. from 2010-21. Methods: We used a retrospective study design using the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) dataset to analyze overdose death rates from any opioid during 2010-21 using ICD-10 codes. We used t-tests and two-way ANOVA to compare the OODR between the U.S. states with the law as compared to those without by using GraphPad Prism 10.0. Results: We found no significant difference in the annual mean age-adjusted OODR from 2010-21 between U.S. states with and without CC SUD laws. During the pre-COVID era (2010-19), the presence or absence of CC SUD law had no difference in age-adjusted OODR. However, in the post-COVID era (2020-21), there was a significant increase in OODR in states with a CC SUD law compared to states without the law (p = 0.032). We also found that OODR increased at a faster rate post-COVID among both the states with CC SUD laws (p < 0.001) and the states without the law (p = 0.019). Conclusion: We found higher age-adjusted OODR in states with a CC SUD law which could be due to the laws being enacted in response to the opioid crisis or physicians' opposition to or unawareness of the law's existence leading to underutilization. Recent enactment of CC SUD law(s), a lack of a central database for recording relapse rates, and disparities in opioid overdose rate reductions uncovers multiple variables potentially influencing OODR. Thus, further investigation is needed to analyze the factors influencing OODRs and long-term effects of the CC SUD laws.

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Fish and other aquatic foods (blue foods) present an opportunity for more sustainable diets1,2. Yet comprehensive comparison has been limited due to sparse inclusion of blue foods in environmental impact studies3,4 relative to the vast diversity of production5. Here we provide standardized estimates of greenhouse gas, nitrogen, phosphorus, freshwater and land stressors for species groups covering nearly three quarters of global production. We find that across all blue foods, farmed bivalves and seaweeds generate the lowest stressors. Capture fisheries predominantly generate greenhouse gas emissions, with small pelagic fishes generating lower emissions than all fed aquaculture, but flatfish and crustaceans generating the highest. Among farmed finfish and crustaceans, silver and bighead carps have the lowest greenhouse gas, nitrogen and phosphorus emissions, but highest water use, while farmed salmon and trout use the least land and water. Finally, we model intervention scenarios and find improving feed conversion ratios reduces stressors across all fed groups, increasing fish yield reduces land and water use by up to half, and optimizing gears reduces capture fishery emissions by more than half for some groups. Collectively, our analysis identifies high-performing blue foods, highlights opportunities to improve environmental performance, advances data-poor environmental assessments, and informs sustainable diets.

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Buprenorphine/Naloxone (Suboxone®) is an efficacious treatment for opioid use disorder (OUD) due to its more convenient dosing, superior safety profile, and decreased incidence of negative side effects when compared to other forms of medications for opioid use disorder (MOUD). In the United States, updated legislation in 2021 entitled, "The Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder", released by the Department of Health and Human Services, creates an exemption for the previously required Drug Addiction Treatment Act of 2000 (DATA) waiver for buprenorphine prescribing for clinicians. This legislation was born out of a need for making MOUD more accessible for patients living with OUD as rates of opioid-related deaths in the United States have continued to rise and have increased disproportionately during the time period of the COVID-19 pandemic. This legislation has the potential to improve access to MOUD across all geographic locations, but may have the most profound impact in rural areas where significant disparities and challenges still exist in patients' ability to access buprenorphine. The purpose of this literature review is to 1) examine how MOUD prescribing has changed after previous legislation changes, 2) explore the current state of buprenorphine access for treatment of OUD in rural America, 3) detail existing barriers in patients' ability to access MOUD, and 4) discuss future directions and considerations as a result of new legislation. This literature review found several existing barriers to receiving MOUD such as increasing costs, insufficient education, significant stigma, and the need for more innovative methods of delivery. We also found that there is currently a large opportunity for growth in the number of rural clinicians able to prescribe buprenorphine, particularly in primary care, that may now occur as a result of this new legislation. Overall, this legislation has the potential to have a positive impact on combating OUD, especially in rural areas, and may be a critical step towards ending the current opioid epidemic in the United States as these described barriers are addressed.

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Concern has been voiced in recent years regarding the environmental implications of the Antarctic krill fishery. Attention has focused primarily on ecological concerns, whereas other environmental aspects, including potentially globally problematic emissions and material and energy demands, have not been examined in detail. Here we apply life cycle assessment to measure the contributions of krill meal, oil, and omega-3 capsules to global warming, ozone depletion, acidification, eutrophication, energy use, and biotic resource use. Supply chains of one krill fishing and processing company, Aker BioMarine of Norway, were assessed. Impacts of krill products were found to be driven primarily by the combustion of fossil fuels onboard the fishing vessel and a transport/resupply vessel. Approximately 190 L of fuel are burned per tonne of raw krill landed, markedly higher than fuel inputs to reduction fisheries targeting other species. In contrast, the biotic resource use associated with extracting krill is relatively low compared to that of other reduction fisheries. Results of this study provide insight into the broader environmental implications of the krill fishery, comparisons between products derived from krill and other species targeted for reduction, opportunities for improving the fishery's performance, and a baseline against which to measure future performance.

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BACKGROUND AND OBJECTIVES: Evaluation of residents' competence is of great importance in the training of physicians, yet the evaluation process is largely subjective. Faculty and residents frequently rely on self assessments to make decisions regarding curriculum design and electives. The In-training Examination (ITE), the only widely available objective measure of residents' medical knowledge, provides an opportunity to test the reliability of self-assessments. This study's objective was to determine if family medicine residents are able to self-assess their medical knowledge by predicting their performance on the ITE. METHODS: A survey asking the residents to estimate their performance on the ITE in each of the nine content areas was administered at 13 examination sites just prior to the ITE. Correlation coefficients were calculated for corresponding predicted and actual scores for each resident in each content area. Predictions were also compared to performance according to quartile. RESULTS: Residents showed little ability to predict their scores in any of the content areas. Residents scoring in either the lowest or highest quartile were least able to predict accurately, with correct predictions ranging from 3% to 23%. CONCLUSIONS: Residents cannot reliably predict their performance on the ITE. Of special concern are residents scoring in the lowest quartile, since these residents greatly overestimated their performance.

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Calciphylaxis is a condition with a high mortality rate that is often found in patients with renal failure. It is characterized by soft tissue calcification and painful skin ulceration. A serum calcium-phosphorus product of more than 60 mg2/dl2 indicates great risk for calciphylaxis. The diagnosis is made on the basis of an incisional biopsy showing calcification of the small, subcutaneous arteries.

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OBJECTIVE: To determine sociodemographic characteristics associated with the initial presentation of Mexican-American elders to a community-based memory evaluation clinic. METHODS: Retrospective review of the charts of 89 Mexican Americans presenting consecutively to an outpatient memory evaluation clinic in San Antonio, Texas. PRINCIPAL FINDINGS: Mexican Americans presented for evaluation with more moderate-to-severe cognitive impairment than previously reported. They also tended to have high levels of IADL (83.1%) and gait/balance (52.3%) impairment, as well as high levels of depressive symptoms (63.1%). CONCLUSIONS: Mexican Americans present for initial evaluation for memory decline with moderate-to-severe cognitive decline and significant dementia-associated co-morbidities. In Mexican Americans, caregiver burden, fall risks, depressive symptoms, and need for IADL support should be addressed on the initial visit for memory decline.

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