Implementation and Evaluation of Whole Health Opioid Safety Shared Medical Appointments in a Veteran Population: A Quality Improvement Study

Problem: The most recent data from the Centers for Disease Control and Prevention (CDC, 2018b) suggest that 130 Americans die from an opioid overdose each day, thus creating an unprecedented number of opioid-related deaths in the United States to date. Context: Of particular interest to the author and this DNP project is that Veterans are twice as likely to die from an opioid overdose, compared to the average American, making this epidemic a priority for Veterans Health Administration (Wilkie, 2018). Interventions: The author developed a 9-session Opioid Safety Shared Medical Appointment (SMA) program to reduce opioid reliance in Veterans using an 8-member interdisciplinary team. Comparisons were made of 90 participants who received training via Cohort I, comprised of 30 participants led by a patient-aligned care team (PACT) that met monthly over 9 months and included health coaching, to Cohort II, comprised of 30 participants led by a PACT team that met weekly over 9 weeks and excluded health coaching, to Cohort III (control), comprised of 30 participants who received training via routine, status quo, in-office education. The curriculum was based on a whole health model and introduced self-care modalities and opioid safety education. A comprehensive whole health toolkit was developed containing resource materials and educational handouts for Veterans to use throughout the course of the opioid SMA. Outcome Measures: Outcome measures for evaluation of this evidence-based project include morphine equivalent daily dose (MEDD), pain scores, and use of complementary alternative modalities (CAMs). Results: Data analysis revealed the only cohort with a statistically significant reduction in MEDD was Cohort I with health coaching (p \u3c 0.0064). Cohort II (without health coaching) did not have a significant reduction in MEDD (p \u3c 0.64) but did have a significant reduction in pain scores (p \u3c 0.02) and a significant increase of CAMs (p \u3e.01). Cohort III (control group in-office education) did not have a significant reduction in MEDD (p \u3c 0.88) or pain scores (p \u3c 0.26) and had no significant increase in the use of CAMs (p \u3c 0.33). However, findings of this work across all three cohorts included clinically significant improvements in MEDD, pain scores, and use of CAMs. Conclusions: Using whole health SMAs may provide an effective, evidenced-based, cost-effective approach to managing chronic pain, decreasing MEDD and pain scores, and increasing CAM use among Veterans. While results support the clinical significance of this model, findings warrant additional investigation. Key words: opioids, Veteran, Veterans Administration, reliance, whole health, shared medical appointment

The influence of storage time and temperature on propofol concentrations in canine blood and plasma.

Propofol is an intravenous anesthetic commonly used due to its favorable pharmacokinetic and pharmacodynamic profile. There are discrepancies in the literature about the most appropriate sample for determining propofol concentrations. Although plasma has been used for determining propofol concentrations, whole blood has been the preferred sample. There is also a lack of consistency in the literature on the effect of storage time and temperature on propofol concentrations and this may lead to errors in the design of pharmacokinetic/pharmacodynamics studies. The purpose of this study was to determine the difference in propofol concentrations in whole blood versus plasma and to evaluate the influence of storage time (56 days) and temperature (4 °C, -20 °C, -80 °C) on the stability of propofol concentrations in blood and plasma samples. Results from the study indicate that whole blood and plasma samples containing propofol stored at -80 °C have concentrations as high as or higher than those stored at 4 °C or -20 °C for 56 days; thus, -80 °C is an appropriate temperature for propofol sample storage. Plasma propofol concentrations were consistently higher than whole blood for all three storage temperatures. Consequently, plasma is the most appropriate sample for propofol analysis due to its consistent determinations

Effects of ciprofloxacin on drug P450 metabolic pathways in pigs

Drugs are potentially toxic substances that elicit dosage-dependent therapeutic effects for specific disease conditions. The efficacy of a drug regimen depends on the concentration of the drug at the site of needed activity and the duration of time it is maintained. The selection of dosing regimens for different species requires the establishment of pharmacokinetic equivalency between species; that is, achieving equivalent peak serum and tissue concentrations and duration of drug exposure. Drug metabolism is a direct reflection of the multiple enzyme systems that characterize different species and is often the most important single factor in regulation if drug concentrations in the body. The largest concentration of enzymes catalyzing these reactions is located in the liver; however, significant concentrations also exist in other tissues such as the intestine. The cytochrome P450 system metabolizes the majority of drugs. Although cytochrome P450 enzymes exist in all species examined to date, minor changes in the structure or tissue distribution of the enzymes may lead to great differences in the metabolism and elimination of specific drugs. A lack of consideration of the rates of biotransformation and elimination of drugs in animals particularly those intended for food may result in drug residues, such as quinolones, in consumed meats. Alternatively, ineffective drug concentrations may prevent killing of bacteria, leading to contamination of meats. More important, low level antibiotic concentrations may favor development of resistant bacterial strains. In an effort to determine pharmacokinetic differences that can indirectly affect development of quinolone resistance in bacteria, differences in quinolone disposition will be identified by allometric analysis of pharmacokinetic data from different species will be analyzed. Activities of specific cytochrome P450 enzymes will be examined in swine

Development of a method for the determination ofhydromorphone in plasma by LC – MS

A simple high‐performance liquid chromatography method for the determination of hydromorphone in small volume plasma has been developed. Following solid‐phase extraction using Oasis HLB cartridges, samples were separated by reverse‐phase high‐performance liquid chromatography on an Atlantis T3 4.6×150mm column (3.0μm) and quantified using mass spectrometry. The mobile phase was a mixture of water with 0.1% formic acid and acetonitrile with 0.1% formic acid (91:9). The stan- dard curve ranged from 1 to 500ng/mL. Intra‐ and Inter‐assay variability for hydromorphone was \u3c10%, and the average recovery was \u3e90%. The LLOQ was 1ng/mL. This method was successfully applied to the analysis of hydromorphone samples at this institution. This method could be useful to those investigators dealing with small sample volumes, particularly when conducting pharmacokinetic studies that require multiple sampling from the same animal

Perfectionism explains variance in self-defeating behaviors beyond self-criticism: Evidence from a cross-national sample

Does perfectionism predict maladjustment beyond self-criticism? Attention to this key question is needed as some studies suggest perfectionism may not explain variance in maladjustment beyond self-criticism. Using a large cross-national sample of 524 undergraduates (229 Canadian, 295 British), this study examined whether evaluative concerns perfectionism (socially prescribed perfectionism, concern over mistakes, doubts about actions) explained variance in self-defeating behaviors (binge eating, procrastination, interpersonal conflict) after controlling for selfcriticism. Results showed that—after controlling for self-criticism—concern over mistakes predicted binge eating, doubts about actions predicted procrastination, and socially prescribed perfectionism and concern over mistakes predicted interpersonal conflict. Self-criticism also uniquely predicted self-defeating behaviors beyond evaluative concerns perfectionism. The relationships that evaluative concerns perfectionism shows with self-defeating behaviors appear neither redundant with nor fully captured by self-criticism. Results dovetail with theoretical accounts suggesting evaluative concerns perfectionism is a uniquely important part of the personality of people prone to self-defeating behaviors

MANDATORY SECOND LANGUAGE LEARNING IN POST-SECONDARY EDUCATION: THE ROLE OF THE IDEAL SELF AND IMAGERY IN MOTIVATION AND ACHIEVEMENT

The majority of language learning in post-secondary higher education is compulsory. Many students in compulsory L2 courses demonstrate lower than average levels of achievement and persistence. Because L2 learning is an important component of a post-secondary education in modern society, improving the motivation to learn languages can improve both achievement and retention.Studies based upon the L2 Motivational Self System (L2 MSS) demonstrate that the variables included in the model have the potential for helping us explain motivation in L2 learning. In addition, an important component of the model is the potential of imagery in enhancing motivation. Much of the research however, examined the salience of the model's key construct rather than examining the relationships among the constructs and their ultimate impact upon second language learning. Moreover, the majority of these studies have been in settings outside the United States with students learning English as a second language and none of the studies examine compulsory language learning.Using a quasi-experimental nonequivalent control group design, 512 college students in beginning level Spanish courses completed pre and post test surveys and an imagery treatment. Path analysis was performed to validate Dörnyei's L2 MSS in the context of US College students (English speakers) in mandatory L2 university courses. Additionally, Analysis of Covariance was performed to examine the use of imagery (ideal self and traditional cultural) to increase motivated learning behavior and intended effort as well as performance in the second language.Data validated the L2 MSS model in a US population of L2 learners in compulsory courses. Results indicated that while all three constructs of the L2 MSS model, ideal L2 self, ought-to L2 self and L2 learning experience, were predictors of motivated learning behavior and intended behavior, they were not equal predictors of performance. Data strongly supported imagery as a priming factor that can link the utility value of learning a language to a perceived future use resulting in student reported increase in interest to learn the L2

In vitro investigation of a terbinafine impregnated subcutaneous implant for veterinary use

A terbinafine impregnated subcutaneous implant was evaluated to determine if drug was released into isotonic saline over the course of 6 months at two different temperatures, 37°C and 4°C. These temperatures were chosen to simulate the nonhibernating (37°C) and hibernating body (4°C) temperatures of little brown bats (Myotis lucifugus). Insectivorous bats of North America, including little brown bats, have been devastated by white nose syndrome, a fungal infection caused by Geomyces destructans. No treatments exist for bats infected with G. destructans. Implants were placed into isotonic saline; samples were collected once per week and analyzed with HPLC to determine terbinafine concentrations. The mean amount of terbinafine released weekly across the 28 weeks was approximately 1.7 μg at 4°C and 4.3 μg at 37°C. Although significant differences in the amount released did occur at some time points, these differences were not consistently greater or less at either of the temperatures. This study showed that terbinafine was released from an impregnated implant over the course of 6 months at concentrations ranging from 0.02 to 0.06 μg/mL depending on temperature, which may be appropriate for little brown bats (Myotis lucifugus) infected with Geomyces destructans, the etiologic agent of white nose syndrome

Determination of Meloxicam in Egg Whites and Yolks Using Reverse Phase Chromatography

A new method of analysis has been developed and validated for the determination of meloxicam in egg whites and yolks. Following a liquid extraction for the whites and a solid phase extraction for the yolks, samples were separated on an XBridge C18 column and quantified using UV detection at 360 nm. The mobile phase was a mixture of water with glacial acetic acid and acetonitrile, with a flow rate of 1 mL/min. The procedure produced a linear curve over the concentration range 5 – 1500 ng/mL with a lower limit of quantification of 5 ng/mL. Intra- and inter-assay variability was 10% or less for both the whites and yolks. The average recovery for whites was 96% and the average recovery in yolks was 97%