Purpose: The Arkansas Hand Trauma Telemedicine Program (AHTTP) is a novel telemedicine system that was developed in 2014 within a rural state to address the growing need of access to hand trauma care with one trauma center that cares for mangling hand injuries. The purpose is to compare transfers for hand injuries prior to and after the implementation of this system. Methods: The hospital institutional database was queried for all transfers to a level 1 medical center in the state from 2012 to 2015, allowing the comparison of data prior to and after the institution of the AHTTP. Patient disposition from the emergency department was categorized to evaluate the impact of AHTTP. Distance, mode of transport, and transport cost were assessed. Findings: There were 202 transfers for the treatment of isolated hand trauma (92 from 2012 to 2013 and 110 from 2014 to 2015). Prior to the institution of AHTTP, transfer patients were admitted 47.8% of the time compared with 68.2% of the time after the development of the program ( P = .02). The approximate cost of transport for patients who were discharged home directly from the emergency department was 38.5% (US $47,233) of the total costs for the 2012-2013 period and was 21.4% (US $34,017) of the costs for the 2014-2015 period ( P < .0001). Conclusions: There was a statistically significant decrease in the number of unnecessary transfers and transportation costs after the telemedicine program was started. The implementation of AHTTP in a rural state reduced health care costs and improved the efficiency of hand specialty care.

Current guidelines recommend restricting acetaminophen (APAP) use in patients with cirrhosis, but evidence to support that recommendation is lacking. Prior studies focused on pharmacokinetics (PK) of APAP in cirrhosis but did not rigorously examine clinical outcomes, sensitive biomarkers of liver damage, or serum APAP-protein adducts, which are a specific marker of toxic bioactivation. Hence, the goal of this pilot study was to test the effects of regularly scheduled APAP dosing in a well-defined compensated cirrhosis group compared to control subjects without cirrhosis, using the abovementioned outcomes. After a 2-week washout, 12 subjects with and 12 subjects without cirrhosis received 650 mg APAP twice per day (1.3 g/day) for 4 days, followed by 650 mg on the morning of day 5. Patients were assessed inperson at study initiation (day 1) and on days 3 and 5. APAP-protein adducts and both conventional (alanine aminotransferase) and sensitive (glutamate dehydrogenase [GLDH], full-length keratin 18 [K18], and total high-mobility group box 1 protein) biomarkers of liver injury were measured in serum on the mornings of days 1, 3, and 5, with detailed PK analysis of APAP, metabolites, and APAP-protein adducts throughout day 5. No subject experienced adverse clinical outcomes. GLDH and K18 were significantly different at baseline but did not change in either group during APAP administration. In contrast, clearance of APAP-protein adducts was dramatically delayed in the cirrhosis group. Minor differences for other APAP metabolites were also detected. Conclusion: Short-term administration of lowdose APAP (650 mg twice per day, <1 week) is likely safe in patients with compensated cirrhosis. These data provide a foundation for future studies to test higher doses, longer treatment, and subjects who are decompensated, especially in light of the remarkably delayed adduct clearance in subjects with cirrhosis. (Hepatology Communications 2021;0:1-13).A cetaminophen (APAP) is the most commonly used analgesic in the United States and throughout much of the world. However, overdose of APAP causes massive centrilobular hepatocyte necrosis that can lead to acute liver failure (ALF) and death. It is overwhelmingly the most common cause of drug-induced ALF in the United States and similarly developed countries, accounting for at least 45%-65% of all cases (1) and possibly even more that go undiagnosed. (2) Although mortality is generally lower in APAP-induced ALF compared to other etiologies, the large number of cases makes APAP overdose the most common cause of ALF-related deaths as well.

After antigen and/or different cytokine stimulation, CD4+ T cells activated and differentiated into distinct T helper (Th) cells via differential T cell signaling pathways. Transcriptional regulation of the activation and differentiation of naïve CD4+ T cells into distinct lineage Th cells such as Th17 cells has been fully studied. However, the role of RNA-binding protein HuR in the signaling pathways of their activation and differentiation has not been well characterized. Here, we used HuR conditional knockout (HuR KO) CD4+ T cells to study mechanisms underlying HuR regulation of T cell activation and differentiation through distinct signaling pathways. Our work showed that, mechanistically, HuR positively promoted CD3g expression by binding its mRNA and enhanced the expression of downstream adaptor Zap70 and Malt1 in activated CD4+ T cells. Compared to WT Th0 cells, HuR KO Th0 cells with reduced Bcl-2 expression are much more susceptible to apoptosis than WT Th0 cells. We also found that HuR stabilized IL-6Rα mRNA and promoted IL-6Rα protein expression, thereby upregulating its downstream phosphorylation of Jak1 and Stat3 and increased level of phosphorylation of IκBα to facilitate Th17 cell differentiation. However, knockout of HuR increased IL-22 production in Th17 cells, which was due to HuR deficiency in reducing IL-22 transcription repressor c-Maf expression. These results highlight the importance of HuR in TCR signaling and IL-6/IL-6R axis driving naïve CD4+ T cell activation and differentiation into Th17 cells.