Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.

BACKGROUND: Unintentional overdose involving opioid analgesics is a leading cause of injury-related death in the United States. OBJECTIVE: To evaluate the feasibility and effect of implementing naloxone prescription to patients prescribed opioids for chronic pain. DESIGN: 2-year nonrandomized intervention study. SETTING: 6 safety-net primary care clinics in San Francisco, California. PARTICIPANTS: 1985 adults receiving long-term opioid therapy for pain. INTERVENTION: Providers and clinic staff were trained and supported in naloxone prescribing. MEASUREMENTS: Outcomes were proportion of patients prescribed naloxone, opioid-related emergency department (ED) visits, and prescribed opioid dose based on chart review. RESULTS: 38.2% of 1985 patients receiving long-term opioids were prescribed naloxone. Patients prescribed higher doses of opioids and with an opioid-related ED visit in the past 12 months were independently more likely to be prescribed naloxone. Patients who received a naloxone prescription had 47% fewer opioid-related ED visits per month in the 6 months after receipt of the prescription (incidence rate ratio [IRR], 0.53 [95% CI, 0.34 to 0.83]; P = 0.005) and 63% fewer visits after 1 year (IRR, 0.37 [CI, 0.22 to 0.64]; P < 0.001) compared with patients who did not receive naloxone. There was no net change over time in opioid dose among those who received naloxone and those who did not (IRR, 1.03 [CI, 0.91 to 1.27]; P = 0.61). LIMITATION: Results are observational and may not be generalizable beyond safety-net settings. CONCLUSION: Naloxone can be coprescribed to primary care patients prescribed opioids for pain. When advised to offer naloxone to all patients receiving opioids, providers may prioritize those with established risk factors. Providing naloxone in primary care settings may have ancillary benefits, such as reducing opioid-related adverse events. PRIMARY FUNDING SOURCE: National Institutes of Health.

Interface quality of different corneal lamellar-cut depths for femtosecond laser-assisted lamellar anterior keratoplasty.

PURPOSE: To evaluate the interface quality of different corneal lamellar-cut depths with the femtosecond laser and determine a feasible range of depth for femtosecond laser-assisted lamellar anterior keratoplasty. SETTING: Casey Eye Institute, Portland, Oregon, USA. DESIGN: Experimental study. METHODS: Full lamellar cuts were made on 20 deepithelialized human cadaver corneas using the femtosecond laser. The cut depth was 17% to 21% (100 µm), 31%, 35%, 38% to 40%, and 45% to 48% of the central stromal thickness. Scanning electron microscopy images of the cap and bed surfaces were subjectively graded for ridge and roughness using a scale of 1 to 5 (1 = best). The graft-host match was evaluated by photography and optical coherence tomography in a simulated procedure. RESULTS: The ridge score was correlated with the cut depth (P = .0078, R = 0.58) and better correlated with the percentage cut depth (P = .00024, R = 0.73). The shallowest cuts had the fewest ridges (score 1.25). The 31% cut depth produced significantly fewer ridges (score 2.15) than deeper cuts. The roughness score ranged from 2.19 to 3.08 for various depths. A simulated procedure using a 100 µm host cut and a 177 µm (31%) graft had a smooth interface and flush anterior junction using an inverted side-cut design. CONCLUSIONS: The femtosecond laser produced more ridges in deeper lamellar cuts. A depth setting of 31% stromal thickness might produce adequate surface quality for femtosecond laser-assisted lamellar anterior keratoplasty. The inverted side-cut design produced good edge apposition even when the graft was thicker than the host lamellar-cut depth. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Evaluating DSAEK graft deturgescence in preservation medium after microkeratome cut with optical coherence tomography.

PURPOSE: To evaluate the Descemet stripping automated endothelial keratoplasty (DSAEK) graft deturgescence in preservation medium after microkeratome cut using Fourier domain optical coherence tomography. METHODS: The central and peripheral thickness of DSAEK grafts was measured by Fourier domain optical coherence tomography immediately after microkeratome cuts and 1, 2, 3, and 4 hours afterward. All measurements were taken when the grafts were stored in 4°C preservation medium. The hourly change in central graft thickness and graft shape (peripheral graft thicknes - central graft thickness) was calculated and tracked over time. RESULTS: Five DSAEK grafts were measured. The average central graft thickness was 188.7 ± 44.4 µm (range, 146-255 µm) immediately after microkeratome cuts. The average central graft thickness was 147.5 ± 33.0 µm (range, 116-190 µm) after 4 hours in preservation medium (P < 0.001). The average hourly change in central graft thickness was -30.5 µm (P = 0.0051), -8.6 µm (P = 0.055), -2.0 µm (P = 0.42), and 0.0 µm (P = 0.93) at 1, 2, 3, and 4 hours, respectively, after microkeratome cuts. The average hourly change in graft shape was insignificant. CONCLUSIONS: DSAEK grafts become thinner after microkeratome cut and stabilize at approximately 2 hours. Therefore, DSAEK graft thickness should be measured at 1.5 to 3 hours after microkeratome cut.

Use of fourier-domain optical coherence tomography to evaluate anterior stromal opacities in donor corneas.

Purpose. To evaluate Fourier-domain optical coherence tomography (FD-OCT) as an adjunct to traditional slit lamp examination of donor corneas with suspected Anterior Stromal Opacities. Methods. Seven corneas suspected of having anterior stromal opacities by slit lamp examination were evaluated with FD-OCT. Each cornea was evaluated to confirm the presence of opacity and, if present, the depth of opacity was measured. Results. The opacity depth ranged from 82 µ m to 624 µ m. The initial slit lamp impressions of five of the seven corneas were confirmed by OCT. In two corneas, the OCT findings were different from the initial slit lamp impressions. Slit lamp examination of the first cornea gave the impression of anterior stromal scarring, but OCT showed that the opacity was limited to the epithelium. Slit lamp examination of the second cornea suggested opacity limited to the epithelium, but OCT identified significant sub-Bowman's scarring. In all cases, the Eye Bank Technicians reported that the location and depth of corneal opacity were more sharply defined by OCT than by slit lamp. Conclusion. The high resolution of OCT makes it easier to determine the location of corneal opacities compared to slit lamp examinations. This enhanced visualization can improve decisions regarding transplant suitability of donor corneas.

Anterior chamber angle evaluation with fourier-domain optical coherence tomography.

New advances in anterior segment optical coherence tomography (OCT) technology development allow visualizing the anterior chamber angle of the eye with high speed and high resolution. Fourier-domain (FD) OCT instruments working at 840 nm can reliably identify fine angle structures such as the Schwalbe's line. This paper demonstrates quantitative angle assessment with 840 nm FD-OCT and provides diagnostic cutoff values for occludable angle detection. This is useful for angle closure glaucoma diagnosis and management. Moreover, 840 nm FD-OCT is a useful tool for postsurgical evaluation in glaucoma patients.