Opioid Dispensing Practices in the Acute Care Setting: A Retrospective Study

Background: Ohio remains one of the most afflicted states nationally with 46.3 per 100 000 deaths due to drug overdose. Opioids are commonly administered in emergency departments for the management of pain. Given the high volume of patients presenting with pain, emergency clinicians must be cognizant of responsible opioid dispensing practices. Ohio established guidelines in April 2012 to provide a general approach for responsible opioid prescribing practices in the emergency setting. The purpose of this study assesses clinician opioid dispensing before and after the implementation of the Ohio Opioid Prescribing Guidelines. Methods: The study design used retrospective data analysis of opioid medications ordered by emergency clinicians to be administered in the emergency room between January 1, 2007, to December 31, 2017, at the University of Toledo Medical Center. A segmented regression analysis with an interrupted time series was used to determine impact. Results: All opioid medication usage showed a significant decrease after guideline implementation except for morphine and fentanyl which showed statistically significant increases in administration over time (P < 0.05). Conclusion: There was a significant decrease in the use of opioids since the implementation of the Ohio Opioid Prescribing Guidelines, yet morphine and fentanyl use has generally increased across all age groups. Age demographics frequently receiving opioids in the emergency room have seemed to shift over time as well as specific opioid drugs dispensed for the management of pain in certain age groups. Further study is needed to evaluate the use of opioids prescribed by emergency physicians after discharge from the emergency department

Evaluation of NAVA-PAP in premature neonates with apnea of prematurity: minimal backup ventilation and clinically significant events

BackgroundNeonates with apnea of prematurity (AOP) clinically deteriorate because continuous positive airway pressure (CPAP) provides inadequate support during apnea. Neurally adjusted ventilatory assist (NAVA) provides proportional ventilator support from the electrical activity of the diaphragm. When the NAVA level is 0 cmH2O/mcV (NAVA-PAP), patients receive CPAP when breathing and backup ventilation when apneic. This study evaluates NAVA-PAP and time spent in backup ventilation.MethodsThis was a prospective, two-center, observational study of preterm neonates on NAVA-PAP for AOP. Ventilator data were downloaded after 24 h. The number of clinically significant events (CSEs) was collected. A paired t-test was used to perform statistical analysis.ResultsThe study was conducted on 28 patients with a gestational age of 25 ± 1.8 weeks and a study age of 28 ± 23 days. The number of CSEs was 4 ± 4.39/24 h. The patients were on NAVA-PAP for approximately 90%/min, switched to backup mode 2.5 ± 1.1 times/min, and spent 10.6 ± 7.2% in backup.ConclusionPreterm neonates on NAVA-PAP had few CSEs with minimal time in backup ventilation

Key stages in mammary gland development: The cues that regulate ductal branching morphogenesis

Part of how the mammary gland fulfills its function of producing and delivering adequate amounts of milk is by forming an extensive tree-like network of branched ducts from a rudimentary epithelial bud. This process, termed branching morphogenesis, begins in fetal development, pauses after birth, resumes in response to estrogens at puberty, and is refined in response to cyclic ovarian stimulation once the margins of the mammary fat pad are met. Thus it is driven by systemic hormonal stimuli that elicit local paracrine interactions between the developing epithelial ducts and their adjacent embryonic mesenchyme or postnatal stroma. This local cellular cross-talk, in turn, orchestrates the tissue remodeling that ultimately produces a mature ductal tree. Although the precise mechanisms are still unclear, our understanding of branching in the mammary gland and elsewhere is rapidly improving. Moreover, many of these mechanisms are hijacked, bypassed, or corrupted during the development and progression of cancer. Thus a clearer understanding of the underlying endocrine and paracrine pathways that regulate mammary branching may shed light on how they contribute to cancer and how their ill effects might be overcome or entirely avoided

Space Charge at Nanoscale: Probing Injection and Dynamic Phenomena Under Dark/Light Configurations by Using KPFM and C-AFM

International audienc

Take only pictures, leave only...fear? The effects of photography on the West Indian anole Anolis cristatellus

Ecotourism encourages an environmentally friendly exploration of the world's natural habitats. Tourists often engage in wildlife photography, an activity that is generally not considered disturbing to animals. We investigated the effects of camera-related stimuli to determine whether shutter noise and/or flash affected the immediate behavior of female crested anoles Anolis cristaellus. Anoles decreased their display rate following stimuli that included shutter noises, but did not change their behavior in response to flash or silence treatments. To determine the relative importance of this response, we observed anole behavior following playbacks of calls from kestrels Falco sparverius, a predator, and bananaquits Coereba flaveola, a non-predator. Anoles decreased display rates following kestrel calls when compared to their response to bananaquit calls. Furthermore, anoles spent a greater proportion of time displaying following bananaquit calls compared to both kestrel calls and silence. The magnitude of response to shutter noises was about the same as that to predator calls. This demonstrates that photography may not be as benign as commonly believed, and we should consider whether restrictions on camera noises should be implemented to reduce animal disturbance [Current Zoology 57 (1): 77–82, 2011]

Nutritional Status Improved in Cystic Fibrosis Patients with the G551D Mutation After Treatment with Ivacaftor

The cystic fibrosis (CF) transmembrane conductance regulator (CFTR) gating mutation G551D prevents sufficient ion transport due to reduced channel-open probability. Ivacaftor, an oral CFTR potentiator, increases the channel-open probability. To further analyze improvements in weight and body mass index (BMI) in two studies of ivacaftor in patients aged a parts per thousand yen6 years with CF and the G551D mutation. Patients were randomized 1:1 to ivacaftor 150 mg or placebo every 12 h for 48 weeks. Primary end point (lung function) was reported previously. Other outcomes included weight and height measurements and CF Questionnaire-Revised (CFQ-R). Studies included 213 patients (aged a parts per thousand currency sign 20 years, n = 105; aged > 20 years, n = 108). In patients a parts per thousand currency sign20 years, adjusted mean change from baseline to week 48 in body weight was 4.9 versus 2.2 kg (ivacaftor vs. placebo, p = 0.0008). At week 48, change from baseline in mean weight-for-age z-score was 0.29 versus -0.06 (p <0.0001); change in mean BMI-for-age z-score was 0.26 versus -0.13 (p <0.0001). In patients > 20 years, adjusted mean change from baseline to week 48 in body weight was 2.7 versus -0.2 kg (p = 0.0003). Mean BMI change at week 48 was 0.9 versus -0.1 kg/m(2) (p = 0.0003). There was no linear correlation evident between changes in body weight and improvements in lung function or sweat chloride. Significant CFQ-R improvements were seen in perception of eating, body image, and sense of ability to gain weight. Nutritional status improved following treatment with ivacaftor for 48 weeks

Modelling the likelihood of entry of marine non-indigenous species from internationally arriving vessels to maritime ports: a case study using New Zealand data

The establishment of marine non-indigenous species (NIS) in new locations can degrade environmental, socio-cultural, and economic values. Vessels arriving from international waters are the main pathway for the entry of marine NIS, via exposure due to ballast water discharge (hereafter, ballast discharge) and biofouling. We developed a systematic statistical likelihood-based methodology to investigate port-level marine NIS propagule pressure from ballast discharge and biofouling exposure using a combination of techniques, namely k-Nearest-Neighbour and random forest algorithms. Vessel characteristics and travel patterns were assessed as candidate predictors. For the ballast discharge analysis, the predictors used for model building were vessel type, dead weight tonnage, and the port of first arrival; the predictors used for the biofouling analysis were days since last antifouling paint, mean vessel speed, dead weight tonnage, and hull niche area. Propagule pressure for both pathways was calculated at a voyage, port and annual level, which were used to establish the relative entry score for each port. The model was applied to a case study for New Zealand. Biosecurity New Zealand has commissioned targeted marine surveillance at selected ports since 2002 to enable early detection of newly arrived marine NIS (Marine High-Risk Site Surveillance, MHRSS). The reported methodology was used to compare contemporary entry likelihoods between New Zealand ports. The results suggested that Tauranga now receives the highest volume of discharged ballast water and has the second most biofouling exposure compared to all other New Zealand ports. Auckland was predicted to receive the highest biofouling mass and was ranked tenth for ballast discharge exposure. Lyttelton, Napier, and New Plymouth also had a high relative ranking for these two pathways. The outputs from this study will inform the refinement of the MHRSS programme, facilitating continued early detection and cost-effective management to support New Zealand’s wider marine biosecurity system. More generally, this paper develops an approach for using statistical models to estimate relative likelihoods of entry of marine NIS

A novel, likely pathogenic variant in UBTF‐related neurodegeneration with brain atrophy is associated with a severe divergent neurodevelopmental phenotype

Abstract Background A de novo, pathogenic, missense variant in UBTF, c.628G>A p.Glu210Lys, has been described as the cause of an emerging neurodegenerative disorder, Childhood‐Onset Neurodegeneration with Brain Atrophy (CONDBA). The p.Glu210Lys alteration yields a positively charged stretch of three lysine residues. Functional studies confirmed this change results in a stronger interaction with negatively charged DNA and gain‐of‐function activity when compared to the wild‐type sequence. The CONDBA phenotype reported in association with p.Glu210Lys consists of normal early‐neurodevelopment followed by progressive motor, cognitive, and behavioral regression in early‐to‐middle childhood. Methods and Results The current proband presented at 9 months of age with baseline developmental delay and more extensive neuroradiological findings, including pontine hypoplasia, thalamic volume loss and signal abnormality, and hypomyelination. Like the recurrent CONDBA p.Glu210Lys variant, this novel variant, c.608A>G p.(Gln203Arg) lies within the highly conserved second HMG‐box homology domain and involves the replacement of the wild‐type residue with a positively charged residue, arginine. Computational structural modeling demonstrates that this amino acid substitution potentiates the interaction between UBTF and DNA, likely resulting in a gain‐of‐function effect for the UBTF protein, UBF. Conclusion Here we present a new divergent phenotype associated with a novel, likely pathogenic, missense variant at a different position in the UBTF gene, c.608A>G p.(Gln203Arg)

Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance

© by the Association of American Medical Colleges. Purpose An evidence-based approach to assessment is critical for ensuring the development of clinical reasoning (CR) competence. The wide array of CR assessment methods creates challenges for selecting assessments fit for the purpose; thus, a synthesis of the current evidence is needed to guide practice. A scoping review was performed to explore the existing menu of CR assessments. Method Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were sorted by assessment methods and reviewed by pairs of authors. Extracted data were used to construct descriptive appendixes, summarizing each method, including common stimuli, response formats, scoring, typical uses, validity considerations, feasibility issues, advantages, and disadvantages. Results A total of 377 articles were included in the final synthesis. The articles broadly fell into three categories: non-workplace-based assessments (e.g., multiple-choice questions, extended matching questions, key feature examinations, script concordance tests); assessments in simulated clinical environments (objective structured clinical examinations and technology-enhanced simulation); and workplace-based assessments (e.g., direct observations, global assessments, oral case presentations, written notes). Validity considerations, feasibility issues, advantages, and disadvantages differed by method. Conclusions There are numerous assessment methods that align with different components of the complex construct of CR. Ensuring competency requires the development of programs of assessment that address all components of CR. Such programs are ideally constructed of complementary assessment methods to account for each method\u27s validity and feasibility issues, advantages, and disadvantages