Postpartum Opioid Use Following Vaginal Deliveries with No or Minor Obstetric Perineal Lacerations

Background: Recommendations for management of pain following vaginal delivery are not specific and do not differentiate patients based on the degree of perineal trauma. Our objective is to describe patterns of postpartum opioid use in women with no or minor perineal trauma. Methods: This is a retrospective cohort study describing the characteristics of opioid analgesia usage among women with no or minor perineal lacerations at the time of vaginal delivery in a university affiliated regional hospital. Results: For the 6-month study period, 433 patients were eligible for inclusion. Of these, 423 (97.69%) were ordered as needed narcotics during their post-partum hospitalization. Of women with an as needed narcotic prescribed, 285 (65.82%) used at least one dose of narcotics while hospitalized. Significant patient characteristics of women using opioids during their inpatient post-partum course included those who used epidural analgesia during labor (p=0.009) and primiparous patients (p=0.05). Thirty-five of the women included in the study received a prescription for opioid analgesics at the time of discharge (8.08%). Significant findings among these women include increasing maternal age (p=0.007). Non-academic physicians with resident coverage were 3.1 times more likely to prescribe opioids at discharge compared to academic physicians with residents and non-academic physicians without resident coverage. Conclusions: Focusing specifically on women with no or minor perineal lacerations at the time of delivery, our findings indicate that if given the option of opioids analgesia during their hospitalization, many women will request at least one dose of opioid analgesia, but rarely require opioids after discharge

Placing care:The Impact of the Physical Environment on Experiences of Providing and Utilizing Palliative Care

Background: Environmental design in palliative and end-of-life care is known to improve care outcomes, service-user satisfaction, and the continuation of service uptake. No study in the literature has investigated the influence of the environment on palliative and end-of-life care in Nigeria or other African contexts.Purpose: This study was designed to explore the impact of the physical environment (i.e., place and people) on staff and service users and how these influence the experiences of providing and using palliative and end-of-life care in a Nigerian hospital context.Methods: Ethnographic methodology was employed because this approach facilitates understanding of environmental realities. This study is part of a larger ethnographic research project developed to uncover aspects of organizational complexities related to the provision and use of palliative and end-of-life care in the Nigerian context. Three hundred fifty hours of participant observation was achieved, and semistructured interviews were used to gather data from 26 participants, including 10 patients, 11 members of a palliative care team, and five hospital managers. Informal chats and photographic capture were additional methods used in data collection. Thematic analysis was conducted to identify and analyze patterns within the collected data.Results: Physical space, equipment, and placing staff were the three primary themes identified. The physical environment was untidy, and the ward layout prevented privacy, dignity, or comfort for patients and families. The equipment was old and inadequate, and the context of care was worsened by insufficient staffing and neglect of the environmental needs of the staff.Conclusions: Hospital design for palliative and end-of-life care in Nigeria is “autoinhibitory” (a negative feedback mechanism whereby hospital design detracts rather than promote quality of care), and a physical environment that supports the provision and utilization of care must be implemented to promote palliative and end-of-life care success. Urgent policy action is needed to improve environmental and staffing conditions to advance palliative and end-of-life care in Nigeria

Distribution and Abundance of Larval Burbot and Deepwater Sculpin in Lake Michigan

Samples from seven locations at depths to 21 m, collected over periods of up to 8 years, were used to describe the nearshore distribution and abundance of burbot Lota lota and deepwater sculpin Myoxocephalus thompsoni larvae in Lake Michigan. Based upon power‐plant‐entrainment samples and field collections, burbot larvae (3.0–7.5 mm) occurred from late March to mid‐June, most abundantly in April and May, and most often at water temperatures of 6–12 C. Larvae were collected from the 0.5‐ to 13.5‐m depth strata as far lakeward as the 21‐m bottom contour, the limit of offshore sampling. In eastern Lake Michigan, highest densities (up to 843 larvae/1,000 m3) were at the 1‐m contour; in Green Bay, up to 24,000 larvae/1,000 m3 were detected near the Bark River. High densities of burbot larvae at bottom depths 3 m and less indicated inshore spawning and river spawning at some sites. Deepwater sculpin larvae first occurred in early February and were common in March and April entrainment samples. Larvae (8.0–22.0 mm) were in nearshore waters usually through May at depth strata of 0.5 to 17 m as far lakeward as the 18‐m bottom contour. Most larvae occurred at water temperatures below 6 C. Field densities were low, 5 to 78 larvae/1,000 m3. Deepwater sculpin larvae were pelagic and were dispersed over great distances by currents.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141932/1/tafs0162.pd

Comparison of sleds versus plankton nets for sampling fish larvae and eggs

Fish larvae and fish eggs were sampled from the inshore waters of eastern Lake Michigan from 1978 through 1980, using a benthic sled and a plankton net towed within 0.5 m of the lake bottom. Differences between estimates of ichthyoplankton abundance based on the benthic sled and those based on the plankton net towed near bottom were examined along with interactions between gear, bottom depth, and time of day. Time of day was determined to be an important factor in comparing these two gear, but data were inconclusive as to the effect of depth on gear differences. Abundance of fish eggs calculated using sled tow data was significantly higher than that for the plankton net. For nighttime collections, density of alewife Alosa pseudoharengus larvae sampled in the plankton net significantly exceeded that for the sled, whereas density of spottail shiner Notropis hudsonius larvae based on sled data was significantly higher than that based on the plankton net for day sampling. Overall, the plankton net appeared to be adequate for sampling abundance of alewife larvae, while the sled was preferred for sampling fish eggs, spottail shiner larvae, and the following less common, but apparently demersal larvae: trout-perch Percopsis omiscomaycus , johnny darter Etheostoma nigrum , ninespine stickleback Pungitius pungitius , and slimy sculpin Cottus cognatus .Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42869/1/10750_2004_Article_BF00015245.pd

Differences in level of confidence in diabetes care between different groups of trainees: the TOPDOC diabetes study

Background There is an increasing prevalence of diabetes. Doctors in training, irrespective of specialty, will have patients with diabetes under their care. The aim of this further evaluation of the TOPDOC Diabetes Study data was to identify if there was any variation in confidence in managing diabetes depending on the geographical location of trainees and career aspirations. Methods An online national survey using a pre-validated questionnaire was administered to trainee doctors. A 4-point confidence rating scale was used to rate confidence in managing aspects of diabetes care and a 6-point scale used to quantify how often trainees would contribute to the management of patients with diabetes. Responses were grouped depending on which UK country trainees were based and their intended career choice. Results Trainees in Northern Ireland reported being less confident in IGT diagnosis, use of IV insulin and peri-operative management and were less likely to adjust oral treatment, contact specialist, educate lifestyle, and optimise treatment. Trainees in Scotland were less likely to contact a specialist, but more likely to educate on lifestyle, change insulin, and offer follow-up advice. In Northern Ireland, Undergraduate (UG) and Postgraduate (PG) training in diagnosis was felt less adequate, PG training in emergencies less adequate, and reporting of need for further training higher. Trainees in Wales felt UG training to be inadequate. In Scotland more trainees felt UG training in diagnosis and optimising treatment was inadequate. Physicians were more likely to report confidence in managing patients with diabetes and to engage in different aspects of diabetes care. Aspiring physicians were less likely to feel the need for more training in diabetes care; however a clear majority still felt they needed more training in all aspects of care. Conclusions Doctors in training have poor confidence levels dealing with diabetes related care issues. Although there is variability between different groups of trainees according to geographical location and career aspirations, this is a UK wide issue. There should be a UK wide standardised approach to improving training for junior doctors in diabetes care with local training guided by specific needs.</p

An Ethnographic Study of Palliative and End-of-Life Care in a Nigerian Hospital:Impact of Education on Care Provision and Utilization

Most clinicians receive little or no palliative care (PC) education. Similarly, patients and their families receive little or no information on PC. Our study explored education in PC, while examining for its impacts on service delivery and utilization from the perspective of health care professionals (HCPs), patients, and their families. An ethnographic approach was utilized to gather data from 41 participants. Spradley’s ethnographic analytical framework guided data analysis. Two themes identified were inadequate HCPs’ knowledge base and impact of service-users’ inadequate health education. The findings show that most HCPs had no formal education in PC, attributed to the lack of PC residency programs and the absence of educational institutions that provide such education. Patients and families also conveyed poor understandings of their illness and palliation, rooted in the HCP culture of partial disclosure of information about their diagnosis, care, and prognosis. Findings suggest a cultural shift that supports PC education for professionals is required to promote realist medical approach in the care for patients with life-limiting illnesses. </jats:p

Burbot Early Life History Strategies in the Great Lakes

Burbot Lota lota exhibit four previously known reproductive strategies in the Great Lakes region. In this paper we review those strategies and provide evidence for a fifth one—delayed deepwater spawning. The four known, shallow‐water strategies are as follows: (1) spawning by self‐sustaining, landlocked populations, (2) spawning in tributaries in winter and the exit of larvae to a Great Lake, (3) spawning by residents in a spawning stream with access to a Great Lake, and (4) spawning on unconsolidated and rocky areas in shallow water in winter in the lake proper. Resident, landlocked populations exist in some Michigan and Wisconsin rivers (e.g., the Muskegon River in Michigan). The evidence for winter tributary spawning is the appearance of newly hatched Burbot in the St. Marys and Bark rivers during April–June. Evidence for Burbot juveniles leaving spawning streams is U.S. Fish and Wildlife Service tributory mouth trap data. The evidence for winter nearshore spawning comes from power plant monthly entrainment studies (Mansfield et al. 1983). Our proposed fifth strategy is spring and summer spawning at deep reefs, where there is probably cobble or boulder habitat. Our evidence comes from midlake reefs in Lake Michigan and offshore areas of Lake Huron: (1) we collected adult Burbot at midlake reefs in Lake Michigan, (2) we collected many Burbot larvae (many of which were newly hatched) from Lakes Michigan and Huron in June–August, and (3) we collected a Burbot egg in a PONAR grab in mid‐July from 73 m in southern Lake Huron. An important question remains, namely, which life history strategy provides the highest recruitment success for this species. It may be that adaptability ensures the survival of this important, top‐predator fish during periods of crisis (e.g., encounters with dams, Sea Lamprey Petromyzon marinus predation).Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141895/1/tafs1733.pd

PPARδ binding to heme oxygenase 1 promoter prevents angiotensin II-induced adipocyte dysfunction in Goldblatt hypertensive rats

Abstract: OBJECTIVE: Renin–angiotensin system (RAS) regulates adipogenic response with adipocyte hypertrophy by increasing oxidative stress. Recent studies have shown the role of peroxisome proliferator-activated receptor-d (PPARδ) agonist in attenuation of angiotensin II-induced oxidative stress. The aim of this study was to explore a potential mechanistic link between PPARδ and the cytoprotective enzyme heme oxygenase-1 (HO-1) and to elucidate the contribution of HO-1 to the adipocyte regulatory effects of PPARδ agonism in an animal model of enhanced RAS, the Goldblatt 2 kidney 1 clip (2K1C) model. METHOD: We first established a direct stimulatory effect of the PPARδ agonist (GW 501516) on the HO-1 gene by demonstrating increased luciferase activity in COS-7 cells transfected with a luciferase-HO-1 promoter construct. Sprague-Dawley rats were divided into four groups: sham-operated animals, 2K1C rats and 2K1C rats treated with GW 501516, in the absence or presence of the HO activity inhibitor, stannous mesoporphyrin (SnMP). RESULTS: 2K1C animals had increased visceral adiposity, adipocyte hypertrophy, increased inflammatory cytokines, increased circulatory and adipose tisssue levels of renin and Ang II along with increased adipose tissue gp91 phox expression (Po0.05) when compared with sham-operated animals. Treatment with GW 501516 increased adipose tissue HO-1 and adiponectin levels (Po0.01) along with enhancement of Wnt10b and b-catenin expression. HO-1 induction was accompanied by the decreased expression of Wnt5b, mesoderm specific transcript (mest) and C/EBPa levels and an increased number of small adipocytes (Po0.05). These effects of GW501516 were reversed in 2K1C animals exposed to SnMP (Po0.05). CONCLUSION: Taken together, our study demonstrates, for the first time, that increased levels of Ang II contribute towards adipose tissue dysregulation, which is abated by PPARδ-mediated upregulation of the heme-HO system. These findings highlight the pivotal role and symbiotic relationship of HO-1, adiponectin and PPARδ in the regulation of metabolic homeostasis in adipose tissues

The social context of food insecurity among persons living with HIV/AIDS in rural Uganda

HIV/AIDS and food insecurity are two of the leading causes of morbidity and mortality in sub-Saharan Africa, with each heightening the vulnerability to, and worsening the severity of, the other. Less research has focused on the social determinants of food insecurity in resource-limited settings, including social support and HIV-related stigma. In this study, we analyzed data from a cohort of 456 persons from the Uganda AIDS Rural Treatment Outcomes study, an ongoing prospective cohort of persons living with HIV/AIDS (PLWHA) initiating HIV antiretroviral therapy in Mbarara, Uganda. Quarterly data were collected by structured interviews. The primary outcome, food insecurity, was measured with the Household Food Insecurity Access Scale. Key covariates of interest included social support, internalized HIV-related stigma, HIV-related enacted stigma, and disclosure of HIV serostatus. Severe food insecurity was highly prevalent overall (38%) and more prevalent among women than among men. Social support, HIV disclosure, and internalized HIV-related stigma were associated with food insecurity; these associations persisted after adjusting for household wealth, employment status, and other previously identified correlates of food insecurity. The adverse effects of internalized stigma persisted in a lagged specification, and the beneficial effect of social support further persisted after the inclusion of fixed effects. International organizations have increasingly advocated for addressing food insecurity as part of HIV/AIDS programming to improve morbidity and mortality. This study provides quantitative evidence on social determinants of food insecurity among PLWHA in resource-limited settings and suggests points of intervention. These findings also indicate that structural interventions to improve social support and/or decrease HIV-related stigma may also improve the food security of PLWHA