Surgical Patient Compliance With Healthcare Facility-Provided In-home Opioid Disposal Products: A Systematic Review.

OBJECTIVE: The aim of this study was to review the literature regarding the use of an in-home opioid disposal product on unused opioids after surgery. BACKGROUND: The opioid epidemic in the United States is a major cause of concern for healthcare facilities. The misuse and diversion of retained opioids after a surgical procedure continues to contribute to this problem. METHODS: A comprehensive search of the Cumulative Index of Nursing and Allied Health Literature, OVID, and PubMed databases with keywords including opioid, analgesics, narcotics, medical waste disposal, medical disposal, refuse disposal, and opioid disposal resulted in 286 articles. Articles were screened based on strict inclusion and exclusion criteria. RESULTS: Eight studies determined that an in-home opioid disposal product provided by a healthcare facility produced rates of opioid disposal between 19% and 71%. CONCLUSIONS: The provision of an in-home opioid disposal product by a healthcare facility is likely to increase the disposal of unused opioid medications in the postoperative surgical patient population.

Compliance With Opioid Disposal Following Opioid Disposal Education in Surgical Patients: A Systematic Review.

PURPOSE: The present opioid epidemic in the United States is a significant cause for concern in healthcare. In 1995, the concept of pain was introduced as the fifth vital sign. Since then, the sales of opioids have increased dramatically, as have the number of opioid deaths. The misuse and diversion of retained opioids following surgical procedures contribute to the problem. The objective of this project was to review the latest scholarly work and evaluate the findings related to patient education and disposal of opioid medications to decrease opioid misuse and increase disposal. DESIGN: A systematic review. METHODS: The systematic search strategy included PubMed, Ovid Technologies (OVID), and Cumulative Index of Nursing and Allied Health Literature (CINAHL) electronic databases. FINDINGS: A total of 4 randomized controlled trials (RCTs), 2 quasi-experimental studies, and 2 quality improvement projects met the criteria for inclusion. The studies found that as many as 92% of patients had leftover unused opioids. The retention rate of opioids among surgical patients was found to be 33 to 95%. When educational material was provided about disposal, the studies found that the disposal rate was as high as 71%. CONCLUSIONS: Patient education about opioid misuse, diversion, and disposal are essential topics that need to be addressed with patients and caregivers.

Comply with regulations or risk paying hefty fines: ten tips for choosing call recording to help ensure compliance.

Medical practices are paying hundreds of thousands of dollars in fines for not complying with various governmental regulations, including a variety of HIPAA rules and credit card compliance. One solution to help reduce this risk and avoid fines is to use call recording to help ensure compliance. This article provides readers with key considerations for choosing and implementing a call recording solution for their medical practices to ensure that it will be compliant with key regulations. These tips include being able to customize call recording policies and procedures for their unique needs; providing secure, private storage; allowing easy access for authorized users; secure sharing of call recordings; regulatory compliance training; disaster recovery; and maintaining an audit-ready and compliant-evident state at all times.

Outsourcing your medical practice call center: how to choose a vendor to ensure regulatory compliance.

Medical practices receive hundreds if not thousands of calls every week from patients, payers, pharmacies, and others. Outsourcing call centers can be a smart move to improve efficiency, lower costs, improve customer care, ensure proper payer management, and ensure regulatory compliance. This article discusses how to know when it's time to move to an outsourced call center, the benefits of making the move, how to choose the right call center, and how to make the transition. It also provides tips on how to manage the call center to ensure the objectives are being met.

Assessment Tools for the Evaluation of Simulation-Based Competency In Ultrasound-Guided Regional Anesthesia: An Integrative Review.

Ultrasound-guided regional anesthesia (UGRA) requires the interaction of technical skills, manual dexterity, and cognitive knowledge which many novice anesthesia providers find challenging. Although simulation improves clinical competency and enhances patient safety, there is no standard tool for assessing UGRA competency in the simulation setting. Therefore, this integrative review aims to determine the most accurate, reliable, and feasible method of evaluating UGRA competency in a simulation environment. Strict inclusion and exclusion criteria were used to conduct this review, yielding 19 articles. The primary objective was the evaluation of validity and reliability outcomes of tools used to assess provider skill level. Secondary objectives were the evaluation of multirater agreement, internal and external reliability, and feasibility. Hand motion analysis and eye motion tracking demonstrated promising results, however, expense and training requirements limit widespread accessibility of those tools. The Regional Anesthesia Procedural Skills tool and McLeod checklist possessed discriminate ability of skill level, high interrater agreement, and feasibility in assessing psychometric competency in simulation. The Naik Global Rating Scale allows for assessment of nontechnical professional attributes. Based on the evidence of this review, the validity and reliability of these tools have the most utility as simulation-based competency tools compared with other tools reviewed.

Fetal protection in heifers vaccinated with a modified-live virus vaccine containing bovine viral diarrhea virus subtypes 1a and 2a and exposed during gestation to cattle persistently infected with bovine viral diarrhea virus subtype 1b.

OBJECTIVE: To determine efficacy of a modified-live virus (MLV) vaccine containing bovine viral diarrhea virus (BVDV) 1a and 2a against fetal infection in heifers exposed to cattle persistently infected (PI) with BVDV subtype 1 b. ANIMALS: 50 heifers and their fetuses. PROCEDURES: Susceptible heifers received a placebo vaccine administered IM or a vaccine containing MLV strains of BVDV1a and BVDV2a administered IM or SC. On day 124 (64 to 89 days of gestation), 50 pregnant heifers (20 vaccinated SC, 20 vaccinated IM, and 10 control heifers) were challenge exposed to 8 PI cattle. On days 207 to 209, fetuses were recovered from heifers and used for testing. RESULTS: 2 control heifers aborted following challenge exposure; both fetuses were unavailable for testing. Eleven fetuses (8 control heifers and 1 IM and 2 SC vaccinates) were positive for BVDV via virus isolation (VI) and for BVDV antigen via immunohistochemical analysis in multiple tissues. Two additional fetuses from IM vaccinates were considered exposed to BVDV (one was seropositive for BVDV and the second was positive via VI in fetal tissues). A third fetus in the SC vaccinates was positive for BVDV via VI from serum alone. Vaccination against BVDV provided fetal protection in IM vaccinated (17/20) and SC vaccinated (17/20) heifers, but all control heifers (10/10) were considered infected. CONCLUSIONS AND CLINICAL RELEVANCE: 1 dose of a BVDV1a and 2a MLV vaccine administered SC or IM prior to breeding helped protect against fetal infection in pregnant heifers exposed to cattle PI with BVDV1b.

Lung pathology and infectious agents in fatal feedlot pneumonias and relationship with mortality, disease onset, and treatments.

This study charted 237 fatal cases of bovine respiratory disease (BRD) observed from May 2002 to May 2003 in a single Oklahoma feed yard. Postmortem lung samples were used for agent identification and histopathology. Late in the study, 94 skin samples (ear notches) were tested for Bovine viral diarrhea virus (BVDV) by immunohistochemistry (IHC). Bovine respiratory disease morbidity was 14.7%, and the mortality rate of all causes was 1.3%, with more than half (53.8%) attributed to BRD (0.7% total of all causes). The agents isolated were the following: Mannheimia haemolytica (25.0%), Pasteurella multocida (24.5%), Histophilus somni (10.0%), Arcanobacterium pyogenes (35.0%), Salmonella spp. (0.5%), and Mycoplasma spp. (71.4%). Viruses recovered by cell culture were BVDV-1a noncytopathic (NCP; 2.7%), BVDV-1a cytopathic (CP) vaccine strain (1.8%), BVDV-1b NCP (2.7%), BVDV-2a NCP (3.2%), BVDV-2b CP (0.5%), and Bovine herpesvirus 1 (2.3%). Gel-based polymerase chain reaction (PCR) assays were 4.6% positive for Bovine respiratory syncytial virus and 10.8% positive for Bovine coronavirus. Bovine viral diarrhea virus IHC testing was positive in 5.3% of the animals. The mean values were determined for the treatment data: fatal disease onset (32.65 days), treatment interval (29.15 days), number of antibiotic treatments (2.65), number of different antibiotics (1.89), and day of death (61.81 days). Lesions included the following: 1) duration: acute (21%), subacute (15%), chronic (40.2%), healing (2.8%), normal (18.1%), and autolyzed (2.8%); 2) type of pneumonia: lobar bronchopneumonia (LBP; 27.1%), LBP with pleuritis (49.1%), interstitial pneumonia (5.1%), bronchointerstitial pneumonia (1.4%), septic (0.9%), embolic foci (0.5%), other (2.8%), normal (10.3%), and autolyzed (2.8%); and 3) bronchiolar lesions: bronchiolitis obliterans (39.7%), bronchiolar necrosis (26.6%), bronchiolitis obliterans/bronchiolar necrosis (1.4%), other bronchiolar lesions (6.5%), and bronchiolar lesion negative (25.7%). Statistically significant relationships were present among the agents, lesions, and the animal treatment, disease onset, and mortality data. Clinical illnesses observed in this study were lengthier than those reported 16-20 years ago, based on fatal disease onset, treatment interval, and day of death.

Diagnostic investigation of emerging viruses of companion animals.

In this article, the authors are specifically concerned with the timely and accurate detection of emerging diseases of small animals that are viral in origin. Veterinarians are bound to encounter emerging viruses in their practice. The problem is unavoidable, because viruses are highly mutagenic. Even the immune response dictates the nature of virus that evolves in a host. If the clinical signs and diagnostic methods fail to correlate, the veterinarian should work with the diagnostic laboratory to solve the diagnostic puzzle.

Postmortem diagnosis of idiopathic hyperammonemia in a horse.

A 6-year-old Quarter Horse stallion was referred to Oklahoma State University Veterinary Medical Teaching Hospital for evaluation of abdominal pain that developed after breeding activity earlier in the day. The horse developed diarrhea and progressively worsening neurologic signs (circling, ataxia, head pressing) within 22 hours of presentation and was subsequently euthanized due to severe self-destructive behavior. Antemortem biochemical and hematologic abnormalities included hypocalcemia but no evidence of hepatic disease. Idiopathic hyperammonemia and encephalopathy were suspected; cerebrospinal fluid (CSF) and aqueous humor were collected 10 hours postmortem for ammonia analysis using a colorimetric assay. Results were compared with those of 6 horses that also had been euthanized, for diseases unrelated to encephalopathy. Ammonia also was measured in plasma samples obtained antemortem. Ammonia concentrations in plasma (958 micromol/L), CSF (1566 micromol/L) and aqueous humor (1018 micromol/L) samples from the stallion were markedly increased compared to those in the 6 unaffected horses (plasma, 9-43 micromol/L; CSF, 370-532 micromol/L; aqueous humor, 70-483 micromol/L). Since the acute nature of hyperammonemic encephalopathy often does not provide sufficient time for an antemortem diagnosis, postmortem analysis of CSF and aqueous humor ammonia concentrations may be a useful alternative for documenting hyperammonemia in horses.

Interstitial pneumonia in neonatal canine pups with evidence of canine distemper virus infection.

Four dead canine pups (5-12 days old) from 3 litters in Douglas County of north central Colorado were submitted to the Colorado State University Diagnostic Laboratory for necropsy. Pups were originally presented to the referring clinics for respiratory tract illness, with or without diarrhea. At necropsy, the lungs from all pups had similar lesions, including random foci of hemorrhage and failure to collapse on opening of the thoracic cavity. The lungs were histologically characterized by subacute interstitial pneumonia, with alveolar septa expanded by a histiocyte-rich infiltrate with a few lymphocytes and neutrophils. The alveolar spaces were filled with moderate amounts of proteinaceous fluid, foamy macrophages, and a few neutrophils. Lungs from 3 of the 4 pups were test positive for canine distemper virus (CDV) by use of reverse transcriptase-polymerase chain reaction (RT-PCR) analysis. Immunohistochemically stained lungs, including those from the pup that were CDV negative, by use of RT-PCR analysis, were test positive for CDV antigen in bronchial and bronchiolar epithelial cells and in a few alveolar macrophages. Central nervous system lesions were not observed in any of the 4 pups. These cases represent an unusual presentation of canine distemper in neonatal pups marked by respiratory tract lesions without central nervous system involvement. Canine distemper should be considered in the differential diagnosis of neonatal canine respiratory tract illness.

Challenge with Bovine viral diarrhea virus by exposure to persistently infected calves: protection by vaccination and negative results of antigen testing in nonvaccinated acutely infected calves.

Calves persistently infected (PI) with Bovine viral diarrhea virus (BVDV) represent an important source of infection for susceptible cattle. We evaluated vaccine efficacy using calves PI with noncytopathic BVDV2a for the challenge and compared tests to detect BVDV in acutely or transiently infected calves versus PI calves. Vaccination with 2 doses of modified live virus vaccine containing BVDV1a and BVDV2a protected the calves exposed to the PI calves: neither viremia nor nasal shedding occurred. An immunohistochemistry test on formalin-fixed ear notches and an antigen-capture enzyme-linked immunosorbent assay on fresh notches in phosphate-buffered saline did not detect BVDV antigen in any of the acutely or transiently infected calves, whereas both tests had positive results in all the PI calves.

Association between findings on palmarodorsal radiographic images and detection of a fracture in the proximal sesamoid bones of forelimbs obtained from cadavers of racing Thoroughbreds.

OBJECTIVE: To determine the distribution for limbs and bones in horses with fractures of the proximal sesamoid bones and relationships with findings on palmarodorsal radiographic images. SAMPLE POPULATION: Proximal sesamoid bones obtained from both forelimbs of cadavers of 328 racing Thoroughbreds. PROCEDURE: Osteophytes; large vascular channels; and fracture location, orientation, configuration, and margin distinctness were categorized by use of high-detail contact palmarodorsal radiographs. Distributions of findings were determined. Relationships between radiographic findings and fracture characteristics were examined by use of chi2 and logistic regression techniques. RESULTS: Fractures were detected in 136 (41.5%) horses. Biaxial fractures were evident in 109 (80%) horses with a fracture. Osteophytes and large vascular channels were evident in 266 (81%) and 325 (99%) horses, respectively. Medial bones typically had complete transverse or split transverse simple fractures, indistinct fracture margins, > 1 vascular channel that was > 1 mm in width, and osteophytes in abaxial wing and basilar middle or basilar abaxial locations. Lateral bones typically had an oblique fracture and distinct fracture margins. Odds of proximal sesamoid bone fracture were approximately 2 to 5 times higher in bones without radiographic evidence of osteophytes or large vascular channels, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: Biaxial fractures of proximal sesamoid bones were common in cadavers of racing Thoroughbreds. Differences between medial and lateral bones for characteristics associated with fracture may relate to differences in fracture pathogeneses for these bones. Osteophytes and vascular channels were common findings; however, fractures were less likely to occur in bones with these features.

Evaluation of diagnostic tests used for detection of bovine viral diarrhea virus and prevalence of subtypes 1a, 1b, and 2a in persistently infected cattle entering a feedlot.

OBJECTIVE: To evaluate diagnostic tests used for detection of bovine viral diarrhea virus (BVDV) and determine the prevalence of BVDV subtypes 1a, 1b, and 2a in persistently infected (PI) cattle entering a feedlot. DESIGN: Prospective study. ANIMALS: 21,743 calves. PROCEDURES: Samples were obtained from calves initially testing positive via antigen capture ELISA (ACE) performed on fresh skin (ear notch) specimens, and ACE was repeated. Additionally, immunohistochemistry (IHC) was performed on skin specimens fixed in neutral-buffered 10% formalin, and reverse transcriptase PCR (RT-PCR) assay and virus isolation were performed on serum samples. Virus was subtyped via sequencing of the 5' untranslated region of the viral genome. RESULTS: Initial ACE results were positive for BVDV in 88 calves. After subsequent testing, results of ACE, IHC, RT-PCR assay, and viral isolation were positive in 86 of 88 calves; results of all subsequent tests were negative in 2 calves. Those 2 calves had false-positive test results. On the basis of IHC results, 86 of 21,743 calves were PI with BVDV, resulting in a prevalence of 0.4%. Distribution of BVDV subtypes was BVDV1b (77.9%), BVDV1a (11.6%), and BVDV2a (10.5%). CONCLUSIONS AND CLINICAL RELEVANCE: Rapid tests such as ACE permit identification and segregation of PI cattle pending results of further tests, thus reducing their contact with the rest of the feedlot population. Although vaccines with BVDV1a and 2a components are given to cattle entering feedlots, these vaccines may not provide adequate protection against BVDV1b.

Acute bovine viral diarrhea associated with extensive mucosal lesions, high morbidity, and mortality in a commercial feedlot.

In 2008, a northwest Texas feedlot underwent an outbreak of Bovine viral diarrhea virus (BVDV) causing high morbidity and mortality involving 2 lots of calves (lots A and B). Severe mucosal surface lesions were observed grossly in the oral cavity, larynx, and esophagus. Mucosal lesions varied from small (1-3 mm) infrequent mucosal ulcerations to large (5 mm to 1 cm) and coalescing ulcerations. Necrotic debris was present in ulcerations of some mortalities with some having plaque-like debris, but other mortalities presented more proliferative lesions. A calf persistently infected with BVDV arrived with one lot and the isolated virus was genotyped as BVDV-1b. Identical BVDV-1b strains were isolated from 2 other mortalities. A BVDV-2a genotype was also isolated in this outbreak. This genotype was identical to all BVDV-2a strains isolated in both lots. Serum samples were collected from exposed and unexposed animals and tested for antibodies for multiple viral pathogens. Seropositivity ranged from zero percent for calicivirus to 100% positive to Pseudocowpox virusx. At the end of the feeding period, the morbidity and mortality for the 2 lots involved was 76.2% and 30.8%, respectively, for lot A, and 49.0% and 5.6%, respectively, for lot B. Differential diagnoses included vesicular stomatitis viruses, Bovine papular stomatitis virus, and Foot-and-mouth disease virus. Based on the present case, acute BVDV should be considered when mucosal lesions are observed grossly.

Multiple diagnostic tests to identify cattle with Bovine viral diarrhea virus and duration of positive test results in persistently infected cattle.

Several tests for Bovine viral diarrhea virus (BVDV) were applied to samples collected monthly from December 20, 2005, through November 27, 2006 (day 0 to day 342) from 12 persistently infected (PI) cattle with BVDV subtypes found in US cattle: BVDV-1a, BVDV-1b, and BVDV-2a. The samples included clotted blood for serum, nasal swabs, and fresh and formalin-fixed ear notches. The tests were as follows: titration of infectious virus in serum and nasal swabs; antigen-capture (AC) enzyme-linked immunosorbent assay (ELISA), or ACE, on serum, nasal swabs, and fresh ear notches; gel-based polymerase chain reaction (PCR) testing of serum, nasal swabs, and fresh ear notches; immunohistochemical (IHC) testing of formalin-fixed ear notches; and serologic testing for BVDV antibodies in serum. Of the 12 animals starting the study, 3 died with mucosal disease. The ACE and IHC tests on ear notches had positive results throughout the study, as did the ACE and PCR tests on serum. There was detectable virus in nasal swabs from all the cattle throughout the study except for a few samples that were toxic to cell cultures. The serum had a virus titer > or = log(10) 1.60 in all samples from all the cattle except for 3 collections from 1 animal. Although there were several equivocal results, the PCR test most often had positive results. The BVDV antibodies were due to vaccination or exposure to heterologous strains and did not appear to interfere with any BVDV test. These findings illustrate that PI cattle may be identified by several tests, but differentiation of PI cattle from cattle with acute BVDV infection requires additional testing, especially of blood samples and nasal swabs positive on initial testing. Also, calves PI with BVDV are continual shedders of infectious virus, as shown by the infectivity of nasal swabs over the 11-mo study.

Prevalence of bovine viral diarrhea virus (BVDV) in persistently infected cattle and BVDV subtypes in affected cattle in beef herds in south central United States.

The prevalence of bovine viral diarrhea virus (BVDV) in persistently infected (PI) cattle in beef breeding herds was determined using 30 herds with 4530 calves. The samples were collected by ear notches and tested for BVDV antigens using immunohistochemistry (IHC) and antigen capture enzyme-linked immunosorbent assay (ACE). Animals with initial positives on both IHC and ACE were sampled again using both tests and serums were collected for viral propagation and sequencing of a viral genomic region, 5'-untranslated region (5'-UTR) for viral subtyping. Samples were also collected from the dams of PI calves. There were 25 PI calves from 4530 samples (0.55%) and these PI calves were from 5 of the 30 herds (16.7%). Two herds had multiple PI calves and 3 herds had only 1 PI calf. Only 1 of the 25 dams with a PI calf was also PI (4.0%). The subtype of all the PI isolates was BVDV1b. Histories of the ranches indicated 23 out of 30 had herd additions of untested breeding females. Twenty-four of the 30 herds had adult cowherd vaccinations against BVDV, primarily using killed BVDV vaccines at pregnancy examination.