Brain Structure and Function of Chronic Low Back Pain Patients on Long-Term Opioid Analgesic Treatment: A Preliminary Study.

Chronic low back pain (CLBP) is often treated with opioid analgesics (OA), a class of medications associated with a significant risk of misuse. However, little is known about how treatment with OA affect the brain in chronic pain patients. Gaining this knowledge is a necessary first step towards understanding OA associated analgesia and elucidating long-term risk of OA misuse. Here we study CLBP patients chronically medicated with opioids without any evidence of misuse and compare them to CLBP patients not on opioids and to healthy controls using structural and functional brain imaging. CLBP patients medicated with OA showed loss of volume in the nucleus accumbens and thalamus, and an overall significant decrease in signal to noise ratio in their sub-cortical areas. Power spectral density analysis (PSD) of frequency content in the accumbens' resting state activity revealed that both medicated and unmedicated patients showed loss of PSD within the slow-5 frequency band (0.01-0.027 Hz) while only CLBP patients on OA showed additional density loss within the slow-4 frequency band (0.027-0.073 Hz). We conclude that chronic treatment with OA is associated with altered brain structure and function within sensory limbic areas.

Vancomycin Area Under the Curve to Predict Timely Clinical Response in the Treatment of Methicillin-resistant Staphylococcus aureus Complicated Skin and Soft Tissue Infections.

INTRODUCTION: Although recent guidelines have recommended monitoring vancomycin (VAN) area under the curve (AUC)/minimum inhibitory concentration (MIC) to ensure clinical efficacy and minimize toxicity in methicillin-resistant Staphylococcus aureus (MRSA) for various infections, there are no recommendations regarding complicated skin and soft tissue infections (cSSTIs). We aimed to evaluate the association between VAN AUC and clinical outcomes in MRSA cSSTIs. METHODS: This was a retrospective cohort study of adult patients treated with ≥72 hours of VAN for MRSA cSSTI from 2008 to 2013 at Detroit Medical Center. The primary outcome was timely clinical success (TCS) defined as (1) resolution of signs and symptoms of infection within 72 hours, (2) stabilization and/or reduction in lesion size, (3) alternative agents not required due to VAN failure or toxicity as elected by the prescribing clinician. Classification and regression tree (CART) analysis was performed to determine the AUC associated with TCS in the cohort. Multivariable logistic regression was used to evaluate the association between VAN-AUC and the primary outcome. RESULTS: A total of 154 patients were included in this analysis. CART identifed an AUC ≥435 mg*hr/L for TCS. Overall, 60.9% of patients experienced TCS; 69.7% in the target-AUC group versus 52.5% in the below-target AUC group, (P = .013). Target-AUC attainment was independently associated with increased odds of TCS (adjusted odds ratio [aOR], 2.208; 95% confidence interval [CI], 1.047-4.659). CONCLUSIONS: In adults treated with VAN for MRSA cSSTI, target-AUC attainment was independently associated with improved clinical outcomes and maybe most warranted for patients at high risk of VAN failure or VAN-associated toxicity.

The impact of chemically enhanced primary treatment on the downstream liquid and solid train processes.

The use of chemical coagulants and flocculants to supplement chemically enhanced primary treatment (CEPT) processes is increasing in popularity as it has been demonstrated to improve carbon redirection and suspended solids and phosphorus removal. Dosing 15 mg ferric chloride/L of wastewater and poly aluminum chloride (PACl; 0.5 mg/L) to the influent of a primary clarifier successfully achieved improved carbon redirection and suspended solids removal at a full-scale WWTP. In this study, the impacts of PACl on the downstream liquid and solid train processes of the same WWTP were investigated. Compared to FeCl3 addition, a combined PACl and FeCl3 addition to the primary influent reduced the TSS and TP concentrations of the secondary clarifier effluent by 20% and 33%, respectively. Effluent BOD5 and ammonia-nitrogen concentrations of the downstream activated sludge process were not affected by the addition of a combined FeCl3 and PACl in the primary clarifier. PACl addition affects the bioavailability of carbon and hence reduced the methane production efficiency of the primary sludge by 20%-30%. However, the significant amount of carbon concentrated in the CEPT sludge would enhance the amount of energy recovered through incineration. PRACTITIONER POINTS: The chemically enhanced primary treatment process is an attractive method for carbon redirection and energy recovery. The combined FeCl3 and PACl addition in the primary clarifier improves the full scale activated sludge process effluent quality. PACl has a negative effect on methane production.

A Quasi-Experiment To Study the Impact of Vancomycin Area under the Concentration-Time Curve-Guided Dosing on Vancomycin-Associated Nephrotoxicity.

Evidence suggests that maintenance of vancomycin trough concentrations at between 15 and 20 mg/liter, as currently recommended, is frequently unnecessary to achieve the daily area under the concentration-time curve (AUC24) target of ≥400 mg · h/liter. Many patients with trough concentrations in this range have AUC24 values in excess of the therapeutic threshold and within the exposure range associated with nephrotoxicity. On the basis of this, the Detroit Medical Center switched from trough concentration-guided dosing to AUC-guided dosing to minimize potentially unnecessary vancomycin exposure. The primary objective of this analysis was to assess the impact of this intervention on vancomycin-associated nephrotoxicity in a single-center, retrospective quasi-experiment of hospitalized adult patients receiving intravenous vancomycin from 2014 to 2015. The primary analysis compared the incidence of nephrotoxicity between patients monitored by assessment of the AUC24 and those monitored by assessment of the trough concentration. Multivariable logistic and Cox proportional hazards regression examined the independent association between the monitoring strategy and nephrotoxicity. Secondary analysis compared vancomycin exposures (total daily dose, AUC, and trough concentrations) between monitoring strategies. Overall, 1,280 patients were included in the analysis. After adjusting for severity of illness, comorbidity, duration of vancomycin therapy, and concomitant receipt of nephrotoxins, AUC-guided dosing was independently associated with lower nephrotoxicity by both logistic regression (odds ratio, 0.52; 95% confidence interval [CI], 0.34 to 0.80; P = 0.003) and Cox proportional hazards regression (hazard ratio, 0.53; 95% CI, 0.35 to 0.78; P = 0.002). AUC-guided dosing was associated with lower total daily vancomycin doses, AUC values, and trough concentrations. Vancomycin AUC-guided dosing was associated with reduced nephrotoxicity, which appeared to be a result of reduced vancomycin exposure.

Early use of daptomycin versus vancomycin for methicillin-resistant Staphylococcus aureus bacteremia with vancomycin minimum inhibitory concentration >1 mg/L: a matched cohort study.

BACKGROUND: Recent reports have described decreased effectiveness with vancomycin treatment for methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) when the vancomycin minimum inhibitory concentration (MIC) is >1 µg/mL. METHODS: This matched, retrospective cohort study compared the clinical effectiveness of daptomycin with that of vancomycin for the treatment of MRSAB with vancomycin MICs >1 µg/mL. The primary outcome was clinical failure, defined as a composite of 30-day mortality or bacteremia persisting for ≥7 days. RESULTS: One hundred seventy patients were matched 1:1 with respect to the antimicrobial administered. In the daptomycin group, all patients received <72 hours of vancomycin (median, 1.7 days [interquartile range, 1.1-2.3 days]) prior to switching to daptomycin. The rate of clinical failure at 30 days was significantly lower in the daptomycin arm compared to the vancomycin arm (20.0% vs 48.2%; P < 0.001). Both 30-day mortality and persistent bacteremia were significantly lower in the daptomycin group compared to the vancomycin group (3.5% vs 12.9% [P = .047] and 18.8% vs 42.4% [P = .001], respectively). Logistic regression confirmed the association between vancomycin treatment and increased risk of clinical failure (adjusted odds ratio, 4.5; 95% confidence interval, 2.1-9.8). CONCLUSIONS: This is the first matched study comparing early daptomycin versus vancomycin for the treatment of MRSAB when the vancomycin MIC is >1 µg/mL. Treatment with daptomycin resulted in significantly improved outcomes, including decreased 30-day mortality and persistent bacteremia. These results support the practice of switching early from vancomycin to daptomycin for the treatment of MRSAB when the vancomycin MIC is >1 µg/mL.

State-scale perspective on water use and production associated with oil and gas operations, Oklahoma, U.S.

A common goal of water and energy management is to maximize the supply of one while minimizing the use of the other, so it is important to understand the relationship between water use and energy production. A larger proportion of horizontal wells and an increasing number of hydraulically fractured well bores are being completed in the United States, and consequently increasing water demand by oil and gas operations. Management, planning, and regulatory decisions for water, oil, and gas are largely made at the state-level; therefore, it is necessary to aggregate water use and energy production data at the state-scale. The purpose of this paper is to quantify annual volumes of water used for completion of oil and gas wells, coproduced during oil and gas production, injected via underground injection program wells, and used in water flooding operations. Data from well completion reports, and tax commission records were synthesized to arrive at these estimates for Oklahoma. Hydraulic fracturing required a median fluid volume of 11,350 m(3) per horizontal well in Oklahoma. Median fluid volume (~15,774 m(3)) and volume per perforated interval (15.73 m(3) m(-1)) were highest for Woodford Shale horizontal wells. State-scale annual water use for oil and gas well completions was estimated to be up to 16.3 Mm(3) in 2011 or less than 1% of statewide freshwater use. Statewide annual produced water volumes ranged from 128.5 to 146.6 Mm(3), with gas wells yielding an estimated 72.4% of the total coproduced water. Volumes of water injected into underground injection control program wells ranged from 206.8 to 305.4 Mm(3), which indicates that water flooding operations may use up to 167.0 Mm(3) per year. State-scale water use estimates for Oklahoma could be improved by requiring oil and gas operators to supplement well completion reports with water use and water production data. Reporting of oil and gas production data by well using a unique identifier (i.e., API number) would also allow for refinement of produced water quantity information. Reporting of wastewater disposal and water flooding volumes could be used to further develop state-scale water accounting and best management practices.

Biomass production and nutrient uptake by Neochloris oleoabundans in an open trough system.

The purpose of this paper is to present biomass and nutrient uptake data from Neochloris oleoabundans production in an open trough system. The growth medium used was BG11, temperature ranged from 16.7 °C to 25.3 °C, and pH ranged from 5.52 to 9.94 because the customary pH increase during algal biomass production was moderated by incoming CO(2) gas streams (atmospheric, 2%, 4%, and 6% CO(2)). Peak concentrations of algal biomass ranged from 643 to 970 mg L(-1), specific growth rates ranged from 0.15 to 0.37 day(-1), and doubling times ranged from 4.8 to 1.9 days. Carbon, nitrogen, and phosphorus were incorporated into the biomass at 0.05%, 8.3%, and 54% of supplied amounts. Open growth systems supplemented with CO(2) should be designed to regulate medium pH within the range of 6.3 to 7.1. Future research should examine various media and alternative carbon sources to decrease doubling times, increase peak concentrations, and optimize nutrient uptake.

Model evaluation of potential impacts of on-site wastewater systems on phosphorus in Turkey creek watershed.

Nutrient loading to surface water systems has traditionally been associated with agricultural sources. Sources such as on-site wastewater systems (OWS) may be of concern especially in rural, nonagricultural watersheds. The impact of various point and nonpoint sources including OWS in Turkey Creek Watershed was evaluated using the Watershed Analysis Risk Management Framework, which was calibrated using 10 yr of observed stream flow and total P concentrations. Doubling the population in the watershed or OWS septic tank effluent P concentration increased mean stream total P concentration by a factor of 1.05. Converting all the OWS to a conventional sewer system with a removal efficiency of 93% at the wastewater treatment plant increased the mean total P concentration at the watershed outlet by a factor of 1.26. Reducing the soil adsorption capacity by 50% increased the mean stream total P concentration by a factor of 3.2. Doubling the initial P concentration increased the mean stream total P concentration by a factor of 1.96. Stream flow and sediment transport also substantially affected stream P concentration. The results suggest that OWS contribution to stream P in this watershed is minimal compared with other factors within the simulated time frame of 10 yr.