Opioid stewardship: a need for opioid discharge guidance: comment on Br J Anaesth 2018 Dec 28

We read with interest the special and insightful article by Soffin and colleagues1 on the prescription opioid crisis. They carefully examine many of the drivers for subsequent opioid dependence after surgery and provide suggestions on how practice can and should be improved. As proponents of enhanced recovery programmes, we acknowledge that with reduced postoperative length of stay, and with the increased utilisation of ambulatory/day surgery, patients are no longer being fully weaned off their analgesics by the time of hospital discharge

Perioperative Opioids - Reclaiming Lost Ground

Opium (poppy tears) has been in use since 3400 BCE, with historical writings recording its sedative, euphoric, and analgesic properties, but it was not until the 19th century that morphine was isolated, paving the way for its therapeutic use. The 20th century witnessed advances in pharmacology and molecular biology, leading to the development of many different types of opioids and the recognition and classification of opioid receptors.Analgesia is fundamental to recovery from surgery, and while opioids continue to be the cornerstone of perioperative analgesia, overreliance on these agents and their many adverse effects has led to a reevaluation of their role in modern perioperative practice. Persistent postoperative opioid use (with disordered substance use at the extreme end of the spectrum) and opioid-induced ventilatory impairment have led to a global opioid crisis that has resulted in more than 100 000 deaths per annum worldwide, a number that rises yearly.1 Persistent postoperative opioid use and opioid-induced ventilatory impairment are exacerbated by other factors, such as nonmedical opioid use and opioid diversion. While the numbers of deaths are clearly not on the scale of the current COVID-19 pandemic, regrettably, there are few signs of measures that will force mortality to recede in the near future. In addition, the financial costs for increased health care and substance use disorder treatment, lost productivity, and criminal justice interventions ran to $150 billion in the US alone in 2015.1 While the opioid epidemic may have originated in the US, it has spread to other areas of the world, with Europe having more than 1.3 million individuals with high-risk opioid use.1 Besides the modifiable risk factors (Box),2 indiscriminate use of opioids has also been fueled by aggressive marketing strategies by pharmaceutical companies and the erroneous impression that consumption of opioids for pain does not lead to substance use disorders

A review of treatment methods for insensitive high explosive contaminated wastewater

Insensitive high explosive materials (IHE) such as 3-nitro-1,2,4-triazol-5-one (NTO) and 2,4-dinitroanisole (DNAN) are increasingly being used in formulations of insensitive munitions alongside 1,3,5-trinitroperhydro1,3,5-triazine (RDX). Load, assembly and packing (LAP) facilities that process munitions produce wastewater contaminated with IHE which must be treated before discharge. Some facilities can produce as much as 90,000 L of contaminated wastewater per day. In this review, methods of wastewater treatment are assessed in terms of their strengths, weaknesses, opportunities and threats for their use in production of IHE munitions including their limitations and how they could be applied to industrial scale LAP facilities. Adsorption is identified as a suitable treatment method, however the high solubility of NTO, up to 16.6 g.L which is 180 times higher that of TNT, has the potential to exceed the adsorptive capacity of carbon adsorption systems. The key properties of the adsorptive materials along the selection of adsorption models are highlighted and recommendations on how the limitations of carbon adsorption systems for IHE wastewater can be overcome are offered, including the modification of carbons to increase adsorptive capacity or reduce costs

Adsorption behaviour of 1,3,5-trinitroperhydro-1,3,5-triazine, 2,4-dinitroanisole and 3-nitro-1,2,4-triazol-5-one on commercial activated carbons

Insensitive high explosives are increasingly being used to replace more sensitive formulations, however large quantities of environmentally hazardous wastewater are generated from loading, assembling and packing processes. Currently, there is limited literature regarding the treatment of wastewater contaminated with these hazardous insensitive high explosive materials such as 1,3,5-trinitroperhydro- 1,3,5-triazine (RDX), 2,4-dinitoranisole (DNAN) and 3-nitro-1,2,4-triazol-5-one (NTO). The preferred method of explosive wastewater treatment is adsorption by activated carbon, usually through treatment columns or fluidised beds that are simple to operate and cost effective. The aim of this research was to assess whether commercially available activated carbons would be suitable and economically viable to treat explosive wastewater containing RDX, DNAN and NTO. Bottle point tests were used to determine adsorption capacity and adsorption kinetics for the individual insensitive high explosives with three different activated carbons. Equilibrium data were fitted to the Langmuir, Freundlich and Temkin isotherms to determine the mechanisms of adsorption. Six hour bottle point tests for a mixture of the three insensitive high explosive constituents were used to consider possible preferential adsorption. As expected, RDX and DNAN were adsorbed at concentrations up to 40 mg.L-1 and 150 mg.L-1 respectively by the activated carbons tested, demonstrating the viability of treatment by adsorption. However, at the high concentrations of NTO expected in wastewater (1400 mg.L-1) activated carbons were rapidly saturated, suggesting that treatment of NTO contaminated wastewater would require prohibitively large quantities of activated carbon compared to RDX and DNAN

Decision framework for the environmental management of explosive contaminated land

The environmental risks from explosive manufacturing and testing activities are usually evaluated using a qualitative process such as environmental impact prioritisation as recommended by legislation and guidance. However, standard environmental management system (EMS) guidance rarely provides detailed information on how to objectively assess the significance of the environmental impacts based on a rational scientific evidence. Quantitative exposure and eco-toxicity assessments are frequently used in combination with environmental threshold limit guidelines, but these omit important environmental impacts such as physical damage to land, nuisance and contribution to climate change. These impacts are particularly relevant to the explosives industry where noise nuisance and physical damage are given high priority. In addition, contamination from explosive compositions may comprise mixtures of multiple legacy and new generation explosives such as 1,3,5-trinitro-1,3,5-triazinane (RDX), 2,4,6-trinitrotoluene (TNT), 5-nitro-1,2,4-triazol-3-one (NTO), 2,4-dinitroanisole (DNAN) and nitroguandine (NQ), which may have combined impacts not captured by conventional eco-toxicity assessments. Further, threshold limits for energetic materials in soil and water have not been established for most nations. Additionally, in the explosive industry wider concerns such as legislative compliance and stakeholder concerns may help to provide a more broadly applicable assessment of environmental impact. Therefore in this study a novel decision framework was developed to integrate empirical data with business risks to enable rational decision making for the environmental management of explosive manufacturing facilities. The application of the framework was illustrated using three case studies from the explosive manufacturing industry to demonstrate how the framework can be used to justify environmental management decision making. By linking the environmental impacts to business risks, we demonstrate that manufacturers are able to assess a wide spectrum of issues that might not be identified in the initial environmental assessment such as non-toxic pollution incidents, breaches in legislation and stakeholder perceptions

The reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist: a joint statement by the ERAS® and ERAS® USA societies

Background: Enhanced Recovery After Surgery (ERAS) programs are multimodal care pathways designed to minimize the physiologic and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. Methods: To improve the quality of ERAS reporting, the ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. Results: The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. Conclusions: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals

Exploring South Africa’s southern frontier: A 20-year vision for polar research through the South African National Antarctic Programme

Antarctica, the sub-Antarctic islands and surrounding Southern Ocean are regarded as one of the planet’s last remaining wildernesses, ‘insulated from threat by [their] remoteness and protection under the Antarctic Treaty System’1 . Antarctica encompasses some of the coldest, windiest and driest habitats on earth. Within the Southern Ocean, sub-Antarctic islands are found between the Sub-Antarctic Front to the north and the Polar Front to the south. Lying in a transition zone between warmer subtropical and cooler Antarctic waters, these islands are important sentinels from which to study climate change.2 A growing body of evidence3,4 now suggests that climatically driven changes in the latitudinal boundaries of these two fronts define the islands’ short- and long-term atmospheric and oceanic circulation patterns. Consequently, sub-Antarctic islands and their associated terrestrial and marine ecosystems offer ideal natural laboratories for studying ecosystem response to change.5 For example, a recent study6 indicates that the shift in the geographical position of the oceanic fronts has disrupted inshore marine ecosystems, with a possible impact on top predators. Importantly, biotic responses are variable as indicated by different population trends of these top predators.7,8 When studied collectively, these variations in species’ demographic patterns point to complex spatial and temporal changes within the broader sub-Antarctic ecosystem, and invite further examination of the interplay between extrinsic and intrinsic drivers

The reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist: a joint statement by the ERAS® and ERAS® USA societies

Background: Enhanced Recovery After Surgery (ERAS) programs are multimodal care pathways designed to minimize the physiologic and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature.Methods: To improve the quality of ERAS reporting, the ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus.Results: The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines.Conclusions: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals

The medical student

The Medical Student was published from 1888-1921 by the students of Boston University School of Medicine

Synchronizing Allelic Effects of Opposing Quantitative Trait Loci Confirmed a Major Epistatic Interaction Affecting Acute Lung Injury Survival in Mice

Increased oxygen (O2) levels help manage severely injured patients, but too much for too long can cause acute lung injury (ALI), acute respiratory distress syndrome (ARDS) and even death. In fact, continuous hyperoxia has become a prototype in rodents to mimic salient clinical and pathological characteristics of ALI/ARDS. To identify genes affecting hyperoxia-induced ALI (HALI), we previously established a mouse model of differential susceptibility. Genetic analysis of backcross and F2 populations derived from sensitive (C57BL/6J; B) and resistant (129X1/SvJ; X1) inbred strains identified five quantitative trait loci (QTLs; Shali1-5) linked to HALI survival time. Interestingly, analysis of these recombinant populations supported opposite within-strain effects on survival for the two major-effect QTLs. Whereas Shali1 alleles imparted the expected survival time effects (i.e., X1 alleles increased HALI resistance and B alleles increased sensitivity), the allelic effects of Shali2 were reversed (i.e., X1 alleles increased HALI sensitivity and B alleles increased resistance). For in vivo validation of these inverse allelic effects, we constructed reciprocal congenic lines to synchronize the sensitivity or resistance alleles of Shali1 and Shali2 within the same strain. Specifically, B-derived Shali1 or Shali2 QTL regions were transferred to X1 mice and X1-derived QTL segments were transferred to B mice. Our previous QTL results predicted that substituting Shali1 B alleles onto the resistant X1 background would add sensitivity. Surprisingly, not only were these mice more sensitive than the resistant X1 strain, they were more sensitive than the sensitive B strain. In stark contrast, substituting the Shali2 interval from the sensitive B strain onto the X1 background markedly increased the survival time. Reciprocal congenic lines confirmed the opposing allelic effects of Shali1 and Shali2 on HALI survival time and provide unique models to identify their respective quantitative trait genes and to critically assess the apparent bidirectional epistatic interactions between these major-effect loci