Sex concordance between physicians and patients and discharge opioid prescribing.

Inpatient pain management is challenging for clinicians and inequities are prevalent. We examined sex concordance between physicians and patients to determine if discordance was associated with disparate opioid prescribing on hospital discharge. We examined 15,339 hospitalizations from 2013 to 2021. Adjusting for patient, clinical, and hospitalization-level characteristics, we calculated the odds of a patient receiving an opioid on discharge and the days of opioids prescribed across all hospitalizations and for patients admitted with a common pain diagnosis. We did not find an overall association between physician-patient sex concordance and discharge opioid prescriptions. Compared to concordant sex pairs, patients in discordant pairs were not significantly less likely to receive an opioid prescription (odds ratio: 1.04; 95% confidence interval [CI]: 0.95, 1.15) and did not receive significantly fewer days of opioids (2.1 fewer days of opioids; 95% CI: -4.4, 0.4). Better understanding relationships between physician and patient characteristics is essential to achieve more equitable prescribing.

Too much information? Males convey parasite levels using more signal modalities than females utilise.

Elaborate sexual signals are thought to have evolved and be maintained to serve as honest indicators of signaller quality. One measure of quality is health, which can be affected by parasite infection. Cnemaspis mysoriensis is a diurnal gecko that is often infested with ectoparasites in the wild, and males of this species express visual (coloured gular patches) and chemical (femoral gland secretions) traits that receivers could assess during social interactions. In this paper, we tested whether ectoparasites affect individual health, and whether signal quality is an indicator of ectoparasite levels. In wild lizards, we found that ectoparasite level was negatively correlated with body condition in both sexes. Moreover, some characteristics of both visual and chemical traits in males were strongly associated with ectoparasite levels. Specifically, males with higher ectoparasite levels had yellow gular patches with lower brightness and chroma, and chemical secretions with a lower proportion of aromatic compounds. We then determined whether ectoparasite levels in males influence female behaviour. Using sequential choice trials, wherein females were provided with either the visual or the chemical signals of wild-caught males that varied in ectoparasite level, we found that only chemical secretions evoked an elevated female response towards less parasitised males. Simultaneous choice trials in which females were exposed to the chemical secretions from males that varied in parasite level further confirmed a preference for males with lower parasites loads. Overall, we find that although health (body condition) or ectoparasite load can be honestly advertised through multiple modalities, the parasite-mediated female response is exclusively driven by chemical signals.

Racial, Ethnic, and Language-Based Inequities in Inpatient Opioid Prescribing by Diagnosis from Internal Medicine Services, a Retrospective Cohort Study.

Introduction: Opioid administration is extremely common in the inpatient setting, yet we do not know how the administration of opioids varies across different medical conditions and patient characteristics on internal medicine services. Our goal was to assess racial, ethnic, and language-based inequities in opioid prescribing practices for patients admitted to internal medicine services. Methods: We conducted a retrospective cohort study of all adult patients admitted to internal medicine services from 2013 to 2021 and identified subcohorts of patients treated for the six most frequent primary hospital conditions (pneumonia, sepsis, cellulitis, gastrointestinal bleed, pyelonephritis/urinary tract infection, and respiratory disease) and three select conditions typically associated with pain (abdominal pain, acute back pain, and pancreatitis). We conducted a negative binomial regression analysis to determine how average administered daily opioids, measured as morphine milligram equivalents (MMEs), were associated with race, ethnicity, and language, while adjusting for additional patient demographics, hospitalization characteristics, medical comorbidities, prior opioid therapy, and substance use disorders. Results: The study cohort included 61,831 patient hospitalizations. In adjusted models, we found that patients with limited English proficiency received significantly fewer opioids (66 MMEs, 95% CI: 52, 80) compared to English-speaking patients (101 MMEs, 95% CI: 91, 111). Asian (59 MMEs, 95% CI: 51, 66), Latinx (89 MMEs, 95% CI: 79, 100), and multi-race/ethnicity patients (81 MMEs, 95% CI: 65, 97) received significantly fewer opioids compared to white patients (103 MMEs, 95% CI: 94, 112). American Indian/Alaska Native (227 MMEs, 95% CI: 110, 344) patients received significantly more opioids. Significant inequities were also identified across race, ethnicity, and language groups when analyses were conducted within the subcohorts. Most notably, Asian and Latinx patients received significantly fewer MMEs and American Indian/Alaska Native patients received significantly more MMEs compared to white patients for the top six most frequent conditions. Most patients from minority groups also received fewer MMEs compared to white patients for three select pain conditions. Discussion. There are notable inequities in opioid prescribing based on patient race, ethnicity, and language status for those admitted to inpatient internal medicine services across all conditions and in the subcohorts of the six most frequent hospital conditions and three pain-associated conditions. This represents an institutional and societal opportunity for quality improvement initiatives to promote equitable pain management.

Pre-clerkship Teaching and Learning in the Virtual Learning Environment: Lessons Learned and Future Directions.

In response to the COVID-19 pandemic, we developed and implemented a theory-informed process to adapt a comprehensive pre-clerkship medical school curriculum to run in the virtual learning environment utilizing sociocultural learning theory and cognitive load theory. Of 124 student respondents, 45% rated virtual learning as very or extremely effective, and 49% as moderately effective. Positive aspects of virtual learning included effectiveness of chat moderators, displaying pronouns on Zoom, active learning technology, and captioning and transcription. Negative aspects included access to technology and feeling isolated from community. Overall course ratings, examination performance, and work hours did not differ pre- and post-implementation.

Optimization of Oxford Nanopore Technology Sequencing Workflow for Detection of Amplicons in Real Time Using ONT-DART Tool.

An optimized, well-tested and validated targeted genomic sequencing-based high-throughput assay is currently not available ready for routine biodefense and biosurveillance applications. Earlier, we addressed this gap by developing and establishing baseline comparisons of a multiplex end-point Polymerase Chain Reaction (PCR) assay followed by Oxford Nanopore Technology (ONT) based amplicon sequencing to real time PCR and customized data processing. Here, we expand upon this effort by identifying the optimal ONT library preparation method for integration into a novel software platform ONT-DART (ONT-Detection of Amplicons in Real-Time). ONT-DART is a dockerized, real-time, amplicon-sequence analysis workflow that is used to reproducibly process and filter read data to support actionable amplicon detection calls based on alignment metrics, within sample statistics, and no-template control data. This analysis pipeline was used to compare four ONT library preparation protocols using R9 and Flongle (FL) flow cells. The two 4-Primer methods tested required the shortest preparation times (5.5 and 6.5 h) for 48 libraries but provided lower fidelity data. The Native Barcoding and Ligation methods required longer preparation times of 8 and 12 h, respectively, and resulted in higher overall data quality. On average, data derived from R9 flow cells produced true positive calls for target organisms more than twice as fast as the lower throughput FL flow cells. These results suggest that utilizing the R9 flowcell with an ONT Native Barcoding amplicon library method in combination with ONT-DART platform analytics provides the best sequencing-based alternative to current PCR-based biodetection methods.

A meta-analysis comparing the outcomes of syndesmotic injury treated with metal screw, dynamic fixation, and bioabsorbable screw.

BACKGROUND: Currently there is significant controversy regarding which fixation method is most effective for the treatment of syndesmotic ankle injuries. OBJECTIVE: This meta-analysis was designed to compare the metal screw, dynamic, and bioabsorbable screw fixation methods for treatment of syndesmotic ankle injuries. METHODS: An online search for RCT and prospective/retrospective clinical comparison studies between January 1998 and December 2018 on syndesmotic fixation was conducted. The main parameters collected include functional scores, mean time to full weightbearing, postoperative tibiofibular clear spaces, tibiofibular overlap, medial clear spaces, and complication rates. Statistical analysis was conducted using One Way ANOVAs and Chi-Squared tests using Review Manager and Excel. RESULTS: A total of 18 comparison studies, with 509 patients in the metal screw fixation group, 275 in the dynamic fixation group, and 226 in the bioabsorbable screw fixation group, were included in this meta-analysis. For the metal screw group, dynamic fixation group, and bioabsorbable screw group, the mean AOFAS score were 83.8, 87.2, and 84.3 (p < 0.05), the mean time to full weightbearing were 9.0 weeks, 7.2 weeks, and 7.7 weeks (p < 0.05), and the complication rates were 0.19, 0.09, and 0.19, respectively (p < 0.05). Similarly, the mean postoperative TFCS were 4.85, 3.87, and 5.70 for the metal screw group, dynamic fixation group, and bioabsorbable screw fixation group, respectively (p < 0.05). CONCLUSION: The dynamic fixation group was found to have significantly improved functional scores, lower complication rates, and lower mean time to full weight-bearing than the metal screw and bioabsorbable screw fixation methods. LEVEL OF EVIDENCE: Meta-analysis of all relevant Level 1-3 Evidence Comparative Studies.

Spinal Cord Stimulation for Chronic Pain Syndromes: A Review of Considerations in Practice Management.

BACKGROUND: Chronic pain syndromes are clinically challenging to treat, and management with opioid medications is increasingly shown to be inappropriate and ineffective. Spinal cord stimulation (SCS) has been demonstrated across numerous high-quality and well-designed studies to be effective in treating various refractory chronic pain. The efficacy and overall success of SCS is highly dependent on compliance to and consideration of various practice patterns. OBJECTIVE: This manuscript is intended to compile and present comprehensive recommendations for key SCS management principles including: a) patient selection criteria, b) efficacy of SCS for various conditions, c) discussion of SCS waveforms, d) trial and permanent implantation considerations, e) periprocedural management, and f) complications and adverse events. STUDY DESIGN: An evidence-based narrative review. METHODS: PubMed, Medline, Cochrane Library, prior systematic reviews, and reference lists were screened by 2 separate authors for all randomized trials, meta-analyses, and observational studies relevant to each of the aforementioned management principles and considered for study inclusion. RESULTS: All high-level evidence studies that explored the various facets of SCS practice management were included for review. LIMITATIONS: Both continued investigation into, and practice implementation of, the various facets of SCS management are necessary to optimize patient outcomes. CONCLUSION: Implementation of and adherence to the evidenced-based recommendations delineated in this publication may help optimize efficacy outcomes and maintain safety profiles for persons treated with SCS interventions.

Pain Syndromes Secondary to Cluneal Nerve Entrapment.

PURPOSE OF REVIEW: The purpose of this review is to provide an overview of the cluneal nerves, present a summary of pain syndromes secondary to clunealgia, and evaluate current literature for diagnostic and treatment modalities. RECENT FINDINGS: Multiple trials and studies have reported success with numerous modalities ranging from nerve blocks, neuroablation, and even peripheral neuromodulation with varying degrees of clinical benefit. Cluneal nerve entrapment or chronic impingement can cause buttock pain or referred pain to nearby areas including the lower back, pelvic area, or even the lower extremities. Clunealgias and associated pain syndromes can often be challenging to diagnose and differentiate. An appreciation of the pathophysiology of clunealgias can assist with patient selection for interventional pain strategies targeted towards the cluneal nerves, including nerve blocks, neuroablation, and peripheral neuromodulation. More research is needed to better delineate the efficacy of these procedures for clunealgias.

Some critical aspects of FT-IR, TGA, powder XRD, EDAX and SEM studies of calcium oxalate urinary calculi.

Urinary calculi constitute one of the oldest afflictions of humans as well as animals, which are occurring globally. The calculi vary in shape, size and composition, which influence their clinical course. They are usually of the mixed-type with varying percentages of the ingredients. In medical management of urinary calculi, either the nature of calculi is to be known or the exact composition of calculi is required. In the present study, two selected calculi were recovered after surgery from two different patients for detailed examination and investigated by using Fourier-Transform infrared spectroscopy (FT-IR), thermo-gravimetric analysis (TGA), powder X-ray diffraction (XRD), scanning electron microscopy and energy dispersive analysis of X-rays (EDAX) techniques. The study demonstrated that the nature of urinary calculi and presence of major phase in mixed calculi could be identified by FT-IR, TGA and powder XRD, however, the exact content of various elements could be found by EDAX only.

Circular permutation directs orthogonal assembly in complex collagen peptide mixtures.

Multiple types of natural collagens specifically assemble and co-exist in the extracellular matrix. Although noncollagenous trimerization domains facilitate the folding of triple-helical regions, it is intriguing to ask whether collagen sequences are also capable of controlling heterospecific association. In this study, we designed a model system mimicking simultaneous specific assembly of two collagen heterotrimers using a genetically inspired operation, circular permutation. Previously, surface charge-pair interactions were optimized on three collagen peptides to promote the formation of an abc-type heterotrimer. Circular permutation of these sequences retained networks of stabilizing interactions, preserving both triple-helical structure and heterospecificity of assembly. Combining original peptides A, B, and C and permuted peptides D, E, and F resulted primarily in formation of A:B:C and D:E:F, a heterospecificity of 2 of 56 possible stoichiometries. This degree of specificity in collagen molecular recognition is unprecedented in natural or synthetic collagens. Analysis of natural collagen sequences indicates low similarity between the neighboring exons. Combining the synthetic collagen model and bioinformatic analysis provides insight on how fibrillar collagens might have arisen from the duplication of smaller domains.

Control of Collagen Stability and Heterotrimer Specificity through Repulsive Electrostatic Interactions.

Charge-pair interactions between acidic and basic residues on the surface of collagen can promote stability as well as control specificity of molecular recognition. Heterotrimeric collagen peptides have been engineered de novo using either rational or computational methods, which in both cases optimize networks of favorable charge-pair interactions in the target structure. Less understood is the role of electrostatic repulsion between groups of like charge in destabilizing structure or directing molecular recognition. To study this, we apply a "charge crowding" approach, where repulsive interactions between multiple aspartate side chains are found to destabilize the homotrimer states in triple helical peptide system and can be utilized to promote the formation of heterotrimers. Neutralizing surface charge by increasing salt concentration or decreasing pH can enhance homotrimer stability, confirming the role of charge crowding on the destabilization of homotrimers via electrostatic repulsion. Charge crowding may be used in conjunction with other approaches to create specific collagen heterotrimers.

(E)-N'-{7-Meth-oxy-spiro-[chromeno[4,3-d]thia-zole-4,1'-cyclo-hexa-n]-2-yl}-N,N-dimethyl-acetimidamide.

In the chromenothia-zole ring system of the title mol-ecule, C(20)H(25)N(3)O(2)S, the pyran ring is in a half-chair conformation. The dihedral angle between the thia-zole and benzene rings is 14.78 (6)°. The cyclo-hexane ring is in a chair conformation. The crystal structure is stabilized by weak inter-molecular C-H⋯N and C-H⋯O hydrogen bonds.

Inhibition of the growth of urinary calcium hydrogen phosphate dihydrate crystals with aqueous extracts of Tribulus terrestris and Bergenia ligulata.

Urinary type calcium hydrogen phosphate dihydrate (CHPD) or Brushite crystals were grown by the single diffusion gel technique in silica hydro-gels. The gel framework acts as a three dimensional crucible in which the crystal nuclei are delicately held in the position of their formation and nutrients are supplied for their growth. This technique can be utilized as a simplified screening model to study the growth and dissolution of urinary stones in vitro. The action of the putatively litholytic medicinal plants Tribulus terrestris and Bergenia ligulata on the growth of CHPD crystals was studied . The effects of artificial reference urine (ARU) and human urine (HU), along with the plant extracts, are also reported. Attempts were made to understand the role of these inhibitors on urinary crystal formation. HU, ARU, extracts of B. ligulata and T. terrestris exhibit appreciable amounts of inhibition, but B.ligulata and T.terrestris with ARU and HU do not show inhibition at all.