Oral Transmucosal Delivery of Fentanyl Citrate for Breakthrough Cancer Pain Relief

Episodes of breakthrough cancer pain are relatively common occurrences for patients undergoing cancer treatments. Characterized by pain unrestrained by traditional medications, these physical burdens impose a significant degree of suffering. In order to control and eliminate this pain, Actiq, a pharmaceutical lollipop, has been developed to provide rapid oral transmucosal delivery of fentanyl citrate, a potent medicinal narcotic. To elucidate the pharmacokinetics of the drug under various dosages, a computer model of fentanyl diffusion in the oral cavity was designed in COMSOL. Upon solving the model process, concentration profiles of fentanyl in the mucosa over time were developed for various dosages. Sensitivity analyses were also performed to determine the effects of several parameters on fentanyl diffusion. The resulting concentration profiles showed that peak concentrations of 0.00079 g/m3, 0.0016 g/m3, and 0.0032 g/m3 for 200 ?g, 400 ?g, and 800 ?g dosages, respectively, were achieved at approximately 800 seconds. Additionally, based upon the sensitivity analyses, the fentanyl solubility and the lollipop radial dissolution rate have the greatest impact on fentanyl concentration and diffusion. Future research can be performed to optimize the drug diffusion by altering these two parameters, ultimately yielding a more effective Actiq product

Assessing the role of bed sediments in the persistence of red mud pollution in a shallow lake (Kinghorn Loch, UK)

Red mud is a by-product of alumina production. Little is known about the long-term fate of red mud constituents in fresh waters or of the processes regulating recovery of fresh waters following pollution control. In 1983, red mud leachate was diverted away from Kinghorn Loch, UK, after many years of polluting this shallow and monomictic lake. We hypothesised that the redox-sensitive constituents of red mud leachate, phosphorus (P), arsenic (As) and vanadium (V), would persist in the Kinghorn Loch for many years following pollution control as a result of cycling between the lake bed sediment and the overlying water column. To test this hypothesis, we conducted a 12-month field campaign in Kinghorn Loch between May 2012 and April 2013 to quantify the seasonal cycling of P, As, and V in relation to environmental conditions (e.g., dissolved oxygen (DO) concentration, pH, redox chemistry and temperature) in the lake surface and bottom waters. To confirm the mechanisms for P, As and V release, a sediment core incubation experiment was conducted using lake sediment sampled in July 2012, in which DO concentrations were manipulated to create either oxic or anoxic conditions similar to the bed conditions found in the lake. The effects on P, As, and V concentrations and species in the water column were measured daily over an eight-day incubation period. Phosphate (PO4-P) and dissolved As concentrations were significantly higher in the bottom waters (75.9 ± 30.2 μg L−1 and 23.5 ± 1.83 μg L−1, respectively) than in the surface waters (12.9 ± 1.50 μg L−1 and 14.1 ± 2.20 μg L−1, respectively) in Kinghorn Loch. Sediment release of As and P under anoxic conditions was confirmed by the incubation experiment and by the significant negative correlations between DO and P and As concentrations in the bottom waters of the lake. In contrast, the highest dissolved V concentrations occurred in the bottom waters of Kinghorn Loch under oxic conditions (15.0 ± 3.35 μg L−1), with the release from the bed sediment apparently being controlled by a combination of competitive ion concentrations, pH and redox conditions

Percutaneous reduction and flexible intramedullary nailing for monteggia fracture in a skeletally mature patient

INTRODUCTION: Monteggia lesions are defined as a fracture of the proximal ulna with an associated radial head dislocation. Management of these injuries varies depending upon the patient population, ranging from non-operative treatment with closed reduction and immobilization to surgical fixation. Percutaneous techniques of radial head reduction are often reserved for skeletally immature patients. PRESENTATION OF CASE: In this case report, a 14-year-old female presented with left elbow pain three days after a fall. Radiographs and CT images from an outside hospital revealed a displaced left radial head fracture and a non-displaced proximal olecranon fracture, consistent with a Monteggia equivalent fracture. The patient underwent percutaneous reduction and internal fixation of the radial head with a flexible intramedullary nail (Metaizeau technique), and open reduction and internal fixation of the olecranon. She developed a 25 degree left elbow flexion contracture and, five months after her index procedure, underwent arthroscopic release and removal of hardware. The radial head reduction was near anatomic and she regained full extension. DISCUSSION: This report demonstrates that percutaneous reduction with intramedullary nailing and fixation techniques can be performed successfully in skeletally mature patients. CONCLUSION: Given their less invasive nature, we recommend attempting percutaneous interventions in some skeletally mature individuals for fracture reduction and fixation

DS_10.1177_1558944718789406 – Supplemental material for Trends in Utilization of Upper Extremity Reconstructive Surgery Following Traumatic Brain Injury and Stroke

<p>Supplemental material, DS_10.1177_1558944718789406 for Trends in Utilization of Upper Extremity Reconstructive Surgery Following Traumatic Brain Injury and Stroke by Bryan G. Beutel, Bryan J. Marascalchi and Eitan Melamed in HAND</p

The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

INTRODUCTION: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance. METHODS: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors related to the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables. RESULTS: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation between Ottawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others. CONCLUSION: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions

The Ottawa Knee Rule: Examining Use in an Academic Emergency Department

Introduction: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance.Methods: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors relatedto the Ottawa Knee Rule. We also performed a retrospective ED record review of patients 13 years of age and older who presented with acute knee trauma to the 3 study EDs during the 2009 calendar year, and we analyzed ED records for 19 variables.Results: ED physicians (n = 47) correctly answered 73.2% of questions assessing knowledge of the Ottawa Knee Rule. The most commonly cited barriers to implementation were “patient expectations” and system issues, such as “orthopedics referral requirement.” We retrospectively reviewed 838 records, with 260 eligible for study inclusion. The rate of Ottawa Knee Rule compliance was retrospectively determined to be 63.1%. We observed a statistically significant correlation betweenOttawa Knee Rule compliance and patient age, but not gender, insurance status, or provider type, among others.Conclusion: Compliance with the Ottawa Knee Rule among academic ED healthcare providers is poor, which was predicted by patient age and not other physician or patient variables. Improving compliance will require comprehensive educational and systemic interventions. [West J Emerg Med. 2012;13(4):366-373.