Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis

Objective Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis. Study Design Retrospective cohort study. Methods History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache. Results Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy. Conclusion Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes. Level of Evidence4. Laryngoscope, 127:1011-1016, 201

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program

Introduction: Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures. Methods: We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation. Results: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45–63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32–51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period. Conclusion: Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes

Transforming Urban Public Transportation: A Lean Enterprise Approach

Much urban mass transportation is perceived as providing second-rate service, existing for the disenfranchised, and possibly not being safe.&nbsp; Once, mass transit recognized and filled a need in major urban areas for efficient intra-city transportation, but people&rsquo;s needs have changed.&nbsp; The goal of this paper is to characterize the current state of urban mass transportation and develop a practical multi-disciplinary business-oriented approach to reenergize transit and to form the type of mass appeal that cars and passenger airlines have.&nbsp; Based on a Lean Enterprise Architecture for transforming the public sector, and using global examples, the authors propose a plan of action to improve and change the image of urban mass transportation

Disposal of Household Wastewater in Soils of High Stone Content (1981-1983)

Four experimental filter fields were constructed with built-in monitoring equipment in Nixa soils. These soils contain many chert fragments and a fragipan about 60 cm below the soil surface. The fragipan restricts downward movement of water and is the designlimitingfeature. The four filter fields were: 1. A standard filter field, 76 cm deep. The bottom of the trench was in the fragipan. 2. A modified standard filter field, 30 cm deep. The bottom of the trench was above the fragipan. 3. A modified pressure filter field, 40 cm deep. The bottom of the trench was above the fragipan. In addition, a pressure-distribution system was used to insure uniform distribution of effluent in the trench. Inadvertently, this field was installed in a different soil, and the results cannot be compared directly with the other three. 4. Another modified pressure filter field with the bottom of the trench only 6 cm below the soil surface. Observation of these systems confirms that placing filter fields higher in the soil above the hydraulically limiting horizon results in improved hydraulic performance. The presence of the fragipan amplified the adverse effects attributable to climatic stress. The seepage beds which are higher in the soil profile are able to handle the effluent load and climate load with less danger of surfacing

3-PG Productivity Modeling of Regenerating Amazon Forests: Climate Sensitivity and Comparison with MODIS-Derived NPP

Potential forest growth predicted by the Physiological Principles in Predicting Growth (3-PG) model was compared for forest and deforested areas in the Legal Amazon to assess potential differing regeneration associated with climate. Historical deforestation and regeneration have occurred in environmentally marginal areas that influence regional carbon sequestration estimates. Effects of El Niño–induced drought further reduce simulated production by decreasing soil water availability in areas with shallow soils and high transpiration potential. The model was calibrated through comparison of literature biomass and with satellite-based estimates. Net primary productivity (NPP) for mature Amazonian forests from the 3-PG model was positively correlated (r 2 = 0.77) with a Moderate Resolution Imaging Spectroradiometer (MODIS)-derived algorithm, though with some bias. Annual total NPP for the study area using a 1961–90 average climatology was 4.6 Pg C yr−1, which decreased to 4.2 Pg C yr−1 when simulated with climate from the severe 1997/98 El Niño event. From a regional analysis, results showed that biomass accumulation is almost entirely controlled by the availability of soil water. Also, areas currently forested in the eastern Amazon are more sensitive to extreme El Niño–induced drought than southern areas with the greatest deforestation extent

Rethinking Appropriateness of Actions in Environmental Decisions: Connecting Interest and Identity Negotiation with Plural Valuation

Issues of interest, identity and values intertwine in environmental conflicts, creating challenges that cannot generally be overcome using rationalities grounded in generalised argumentation and abstraction. To address the growing need to engage interests and identities along with plural values in the conservation of biodiversity and ecological systems, we introduce the concept of ‘appropriateness of actions’ and ground it in a relational understanding of environmental ethics. A determination of appropriateness for actions comes from combining outputs from value elicitation with those of interest and identity negotiation in ways that are salient to specific people and their relationships to specific places. Drawing on the Blue Mountain Forest Partnership in the Pacific Northwest, we propose factors of success for supporting appropriate actions: 1) understanding context and identifying key stakeholders; 2) surfacing a diversity of interests and building system-level trust; 3) building empathy for different identities grounded in specific places; 4) eliciting diverse values and seeking to understand their links to worldviews and knowledge systems and; 5) seeking out appropriate actions

In the Supreme Court of the United States Barbara Grutter, Petitioner, v. Lee Bollinger, et al., Respondents. On Writ of Certiorari to the United States Court of Appeals for the Sixth Circuit

Brief of the University of Michigan Asian Pacific American Law Students Association, the University of Michigan Black Law Students\u27 Alliance, the University of Michigan Latino Law Students Association, and the University of Michigan Native American Law Students Association as Amici Curiae in Support of Respondent

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality

OBJECTIVE: Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds. We quantify dose-dependent overdose mortality over a large spectrum of clinically common doses. We also examine the contributions of benzodiazepines and extended release opioid formulations to mortality. DESIGN: Prospective observational cohort with one year follow-up. SETTING: One year in one state (NC) using a controlled substances prescription monitoring program, with name-linked mortality data. SUBJECTS: Residential population of North Carolina (n = 9,560,234), with 2,182,374 opioid analgesic patients. METHODS: Exposure was dispensed prescriptions of solid oral and transdermal opioid analgesics; person-years calculated using intent-to-treat principles. Outcome was overdose deaths involving opioid analgesics in a primary or additive role. Poisson models were created, implemented using generalized estimating equations. RESULTS: Opioid analgesics were dispensed to 22.8% of residents. Among licensed clinicians, 89.6% prescribed opioid analgesics, and 40.0% prescribed ER formulations. There were 629 overdose deaths, half of which had an opioid analgesic prescription active on the day of death. Of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Mortality rates increased gradually across the range of average daily milligrams of morphine equivalents. 80.0% of opioid analgesic patients also received benzodiazepines. Rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher (7.0 per 10,000 person-years, 95 percent CI: 6.3, 7.8) than opioid analgesics alone (0.7 per 10,000 person years, 95 percent CI: 0.6, 0.9). CONCLUSIONS: Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. There is urgent need for guidance about combined classes of medicines to facilitate a better balance between pain relief and overdose risk