Implementation of a clinical pathway to screen and treat medical inpatients for opioid withdrawal.

Background: Opioid-related inpatient hospital stays are increasing at alarming rates. Unidentified and poorly treated opioid withdrawal may be associated with inpatients leaving against medical advice and increased health care utilization. To address these concerns, we developed and implemented a clinical pathway to screen and treat medical service inpatients for opioid withdrawal. Methods: The pathway process included a two-item universal screening instrument to identify opioid withdrawal risk (Opioid Withdrawal Risk Assessment [OWRA]), use of the validated Clinical Opiate Withdrawal Scale (COWS) to monitor opioid withdrawal symptoms and severity, and a 72-h buprenorphine/naloxone-based treatment protocol. Implementation outcomes including adoption, fidelity, and sustainability of this new pathway model were measured. To assess if there were changes in nursing staff acceptability, appropriateness, and adoption of the new pathway process, a cross-sectional survey was administered to pilot four hospital medical units before and after pathway implementation. Results: Between 2016 and 2018, 72.4% (77,483/107,071) of admitted patients received the OWRA screening tool. Of those, 3.0% (2,347/77,483) were identified at risk for opioid withdrawal. Of those 2,347 patients, 2,178 (92.8%) were assessed with the COWS and 29.6% (645/2,178) were found to be in active withdrawal. A total of 49.5% (319/645) patients were treated with buprenorphine/naloxone. Fifty-seven percent (83/145) of nurses completed both the pre- and post-pathway implementation surveys. Analysis of the pre/post survey data revealed that nurse respondents were more confident in their ability to determine which patients were at risk for withdrawal (p = .01) and identify patients currently experiencing withdrawal (p < .01). However, they cited difficulty working with the patient population and coordinating care with physicians. Conclusions: Our study demonstrates a process for successfully implementing and sustaining a clinical pathway to screen and treat medical service inpatients for opioid withdrawal. Standardizing care delivery for patients in opioid withdrawal can also improve nursing confidence when working with this complex population.

Staging canine patients with appendicular osteosarcoma utilizing fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography compared to whole body computed tomography.

Few studies have investigated the diagnostic performance of fluorine-18-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) for staging veterinary patients with appendicular osteosarcoma. The purpose of this study was to evaluate the efficacy of 18 F-FDG-PET/CT compared to whole-body CT (WBCT) for staging canine patients with appendicular osteosarcoma. The 18 F-FDG-PET/CT imaging studies of 66 dogs with appendicular osteosarcoma were anonymized and separated into two detached studies (one with whole body pre- and post-contrast CT images and the other with the whole body pre- and post-contrast CT images with the associated 18 F-FDG-PET overlay). Image assessment was performed retrospectively by five board-certified veterinary radiologists. The radiologists were instructed to assign a predefined categorical score (1-4) to each pre-designated anatomic region based on a devised lesional scoring system. A score of 1 was normal, 2 abnormal but not neoplastic, 3 abnormal and concerning for neoplasia, and 4 abnormal, most likely neoplastic. Overall, the likelihood of detection of '3 or 4' was found to be significantly higher with 18 F-FDG PET/CT when compared to WBCT after adjusting for the effect of evaluator and the subject. Most significantly, 13 osseous lesions concerning for metastasis (scored 3-4) were identified in 10/66 dogs by at least one reviewer on 18 F-FDG PET/CT, which were not identified by any reviewer on WBCT. Additionally, four comorbid neoplastic lesions were identified with 18 F-FDG PET/CT and not with WBCT. The results of this study suggest that 18 F-FDG PET/CT is more efficacious in detecting metastatic and comorbid neoplastic lesions compared to WBCT in dogs with appendicular osteosarcoma.

Optimising service users and carers involvement in nursing and social work pre-registration degrees.

The awareness of the contribution of service users and carers' involvement in nursing and social work pre-registration degree education continues to grow. This study explored ways of optimising its beneficial outcomes to students, service users/carers and academic staff. A phenomenology qualitative approach was employed. The study sample was drawn from service users/carers involved in students' education, and adult nursing and social work degree students and academic staff. A total of 38 participants took part. Semi-structured interviews were used to gather views, which was then thematically analysed. This study identified factors that can optimise the beneficial outcomes of service users and carers' involvement to students, service users/carers and academic staff in Adult nursing and Social work pre-registration degree. The findings of this study support the value of service users' and carers' involvement in undergraduate nursing and social work education and offer strategies which support best practice, and optimise and sustain the efficacy and benefits of this approach in a higher education setting. An understanding of issues related to optimising service user and carer involvement may assist in the development of strategies that continue to make service users and carers' involvement in nursing and social work pre-registration degree effective and meaningful to students, service users/carers and academic staff.

Diagnostic Ultrasound Detection of Changes in Femoral Muscle Mass Recovery after Tibial Plateau Levelling Osteotomy in Dogs.

OBJECTIVE: The goal of this study was to develop a clinically feasible ultrasound (US) protocol that can detect changes in thigh muscle mass in dogs after stifle surgery. The primary aim of this study was to compare previously described US measurement locations of the canine thigh for detecting changes in muscle mass in dogs recovering from tibial plateau levelling osteotomy (TPLO). STUDY DESIGN: This was a prospective, exploratory pilot study. Adult dogs (n = 7) undergoing pet-owner elected TPLO were enrolled. Twelve different US measurements were performed in triplicate by a single experienced observer. Measurements were performed at 0, 2, 4 and 8 weeks after surgery at a proximal and distal location along the femur. Data from all available time points and locations were analysed for the main effect of time within modalities. RESULTS: A total of 1,008 US measurements were performed. Measurements of the transverse sectional area of the rectus femoris muscle detected significant (p ≤ 0.05) muscle loss between weeks 0 and 2 at the lateral and medial aspects of the distal location (19% and 15% respectively). Measurements of the thigh muscle thickness were significantly (p < 0.01) increased between 2nd- and 8th- week time points at the lateral aspect of the proximal location (26%). CONCLUSION: The proximal femoral location, measured from the lateral aspect, appears to be the most suitable US measurement for detecting increases in femoral muscle mass in dogs recovering from TPLO. The provided pilot data suggest that further research evaluating this outcome measure is indicated.

Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis.

OBJECTIVES: Detection of dementia is essential for improving the lives of patients but the extent of underdetection worldwide and its causes are not known. This study aimed to quantify the prevalence of undetected dementia and to examine its correlates. METHODS/SETTING/PARTICIPANTS: A systematic search was conducted until October 2016 for studies reporting the proportion of undetected dementia and/or its determinants in either the community or in residential care settings worldwide. Random-effects models calculated the pooled rate of undetected dementia and subgroup analyses were conducted to identify determinants of the variation. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measures of interest were the prevalence and determinants of undetected dementia. RESULTS: 23 studies were eligible for inclusion in this review. The pooled rate of undetected dementia was 61.7% (95% CI 55.0% to 68.0%). The rate of underdetection was higher in China and India (vs Europe and North America), in the community setting (vs residential/nursing care), age of <70 years, male gender and diagnosis by general practitioner. However, it was lower in the studies using Mini-Mental State Examination (MMSE) diagnosis criteria. CONCLUSIONS: The prevalence of undetected dementia is high globally. Wide variations in detecting dementia need to be urgently examined, particularly in populations with low socioeconomic status. Efforts are required to reduce diagnostic inequality and to improve early diagnosis in the community.

Demographic and socio-economic influences on community-based care and caregivers of people with dementia in China.

BACKGROUND: Dementia is a major public health challenge and China has the largest population with dementia in the world. However, dementia care and caregivers for Chinese are less investigated. OBJECTIVES AND DESIGN: To evaluate demographic and socio-economic influences on dementia care, management patterns and caregiver burden in a household community-dwelling-based survey, using participants' care receipts and Zarit scale. SETTING AND PARTICIPANTS: Rural and urban communities across six provinces of China comprising 4837 residents aged ≥60 years, in whom 398 had dementia and 1312 non-dementia diseases. RESULTS: People with dementia were less likely to receive care if they were living in rural compared to urban areas (Odd ratio (OR) = 0.20; 95%CI: 0.10-0.41), having education level below compared to above secondary school (OR = 0.24; 95%CI: 0.08-0.70), manual labourer compared to non-manual workers (OR = 0.27; 95%CI: 0.13-0.55), having personal annual income below RMB 10,000 yuan (£1000) compared to above (OR = 0.37; 95%CI: 0.13-0.74) or having four or more than compared to less four children (OR = 0.52; 95%CI: 0.27-1.00). Caregivers for dementia compared with those for non-dementia diseases were younger and more likely to be patients' children or children in-law, had lower education and spent more caring time. Caregiver burden increased with low education, cutback on work and caring for patients who were younger or living in rural areas, and this caregiver burden was three-fold greater than that for non-dementia diseases. CONCLUSIONS: There are a number of inequalities in dementia care and caregiver burden in China. Reducing the socio-economic gap and increasing education may improve community care for people with dementia and preserve caregivers' well-being.

COMPUTED TOMOGRAPHY OF TOOTH RESORPTION IN CATS.

Tooth resorption is the most common dental disease in cats and can be a source of oral pain. The current clinical gold standard for diagnosis includes a combination of oral exam and dental radiography, however early lesions are not always detected. Computed tomography (CT) of the skull, including the dental arches, is a commonly performed diagnostic procedure, however the appearance of tooth resorption on CT and the diagnostic ability of CT to detect tooth resorption have not been evaluated. The purpose of this prospective, descriptive, diagnostic accuracy study was to characterize the CT appearance of tooth resorption in a sample of affected cats and to evaluate the sensitivity and specificity of CT for tooth resorption compared to the clinical gold standard of oral exam and intraoral dental radiography. Twenty-eight cat cadaver specimens were recruited for inclusion. Each specimen was evaluated using oral exam, intraoral dental radiography, and computed tomography (four different slice thicknesses). Each tooth was evaluated for the presence or absence of tooth resorption. Teeth with lesions and a subset of normal teeth were evaluated with histopathology. On CT, tooth resorption appeared as irregularly marginated hypoattenuating defects in the mineral attenuating tooth components, most commonly involving the root or cementoenamel junction. Sensitivity for CT detection of tooth resorption was fair to poor (42.2-57.7%) and specificity was good to excellent (92.8-96.3%). Findings from this study indicated that CT has high specificity but low sensitivity for detection of tooth resorption in cats.

Exposure to air pollution and cognitive functioning across the life course--A systematic literature review.

OBJECTIVES: Air pollution is associated with increased risk of respiratory, cardiovascular and cerebrovascular disease, but its association with cognitive functioning and impairment is unclear. The aim of this systematic review was to examine whether a relationship exists between these variables across the life course. METHODS: We searched Web of Knowledge, Pubmed, SciVerse Scopus, CINAHL, PsychInfo and Science Direct up to October 2015 to identify studies that investigated the association between air pollution and performance on neurocognitive tests. RESULTS: Variations in exposure assessment and outcome measures make meta-analysis impossible. Thirty one studies published between 2006 and 2015, from the Americas (n=15), Asia (n=5) and Europe (n=11), met the criteria for inclusion. Many showed weak but quantified relationships between various air pollutants and cognitive function. Pollution exposure in utero has been associated with increased risk of neuro-developmental delay. Exposure in childhood has been inversely associated with neuro-developmental outcomes in younger children and with academic achievement and neurocognitive performance in older children. In older adults, air pollution has been associated with accelerated cognitive decline. CONCLUSIONS: The evidence to date is coherent in that exposure to a range of largely traffic-related pollutants has been associated with quantifiable impairment of brain development in the young and cognitive decline in the elderly. There is insufficient evidence at present to comment on consistency, in view of the different indices of pollution and end-points measured, the limited number of studies, and the probability at this stage of publication bias. However, plausible toxicological mechanisms have been demonstrated and the evidence as a whole suggests that vehicular pollution, at least, contributes to cognitive impairment, adding to pressure on governments and individuals to continue to reduce air pollution.

Is exposure to secondhand smoke associated with cognitive parameters of children and adolescents?--a systematic literature review.

PURPOSE: Despite the known association of second hand smoke (SHS) with increased risk of ill health and mortality, the effects of SHS exposure on cognitive functioning in children and adolescents are unclear. Through a critical review of the literature we sought to determine whether a relationship exists between these variables. METHODS: The authors systematically reviewed articles (dated 1989-2012) that investigated the association between SHS exposure (including in utero due to SHS exposure by pregnant women) and performance on neurocognitive and academic tests. Eligible studies were identified from searches of Web of Knowledge, MEDLINE, Science Direct, Google Scholar, CINAHL, EMBASE, Zetoc, and Clinicaltrials.gov. RESULTS: Fifteen articles were identified, of which 12 showed inverse relationships between SHS and cognitive parameters. Prenatal SHS exposure was inversely associated with neurodevelopmental outcomes in young children, whereas postnatal SHS exposure was associated with poor academic achievement and neurocognitive performance in older children and adolescents. Furthermore, SHS exposure was associated with an increased risk of neurodevelopmental delay. CONCLUSIONS: Recommendations should be made to the public to avoid sources of SHS and future research should investigate interactions between SHS exposure and other risk factors for delayed neurodevelopment and poor cognitive performance.

Surfactant protein-A modulates LPS-induced TLR4 localization and signaling via ß-arrestin 2.

The soluble C-type lectin surfactant protein (SP)-A mediates lung immune responses partially via its direct effects on alveolar macrophages (AM), the main resident leukocytes exposed to antigens. SP-A modulates the AM threshold of lipopolysaccharide (LPS) activity towards an anti-inflammatory phenotype both in vitro and in vivo through various mechanisms. LPS responses are tightly regulated via distinct pathways including subcellular TLR4 localization and thus ligand sensing. The cytosolic scaffold and signaling protein ß-arrestin 2 acts as negative regulator of LPS-induced TLR4 activation. Here we show that SP-A neither increases TLR4 abundancy nor co-localizes with TLR4 in primary AM. SP-A significantly reduces the LPS-induced co-localization of TLR4 with the early endosome antigen (EEA) 1 by promoting the co-localization of TLR4 with the post-Golgi compartment marker Vti1b in freshly isolated AM from rats and wild-type (WT) mice, but not in ß-arrestin 2(-/-) AM. Compared to WT mice pulmonary LPS-induced TNF-α release in ß-arrestin 2(-/-) mice is accelerated and enhanced and exogenous SP-A fails to inhibit both lung LPS-induced TNF-α release and TLR4/EEA1 positioning. SP-A, but not LPS, enhances ß-arrestin 2 protein expression in a time-dependent manner in primary rat AM. The constitutive expression of ß-arrestin 2 in AM from SP-A(-/-) mice is significantly reduced compared to SP-A(+/+) mice and is rescued by SP-A. Prolonged endosome retention of LPS-induced TLR4 in AM from SP-A(-/-) mice is restored by exogenous SP-A, and is antagonized by ß-arrestin 2 blocking peptides. LPS induces ß-arrestin 2/TLR4 association in primary AM which is further enhanced by SP-A. The data demonstrate that SP-A modulates LPS-induced TLR4 trafficking and signaling in vitro and in vivo engaging ß-arrestin 2.

Effects of maternal cigarette smoking during pregnancy on cognitive parameters of children and young adults: a literature review.

The long term effects of maternal smoking during pregnancy on the cognitive development of the child are not well understood due to conflicting findings in past research. The aim of this paper was to provide an up to date, critical review of the literature to determine whether there is evidence of a relationship between tobacco smoke exposure in utero and cognitive functioning. We systematically reviewed observational studies (dated 2000-2011) that examined associations between tobacco smoke exposure in utero due to maternal smoking and performance on cognitive, intelligence, neurodevelopmental and academic tests. Eligible studies were identified through searches of Web of Knowledge, Medline, Science Direct, Google Scholar, CINAHL, EMBASE, Zetoc and Clinicaltrials.gov databases. The review found evidence of a relationship between tobacco smoke exposure in utero and reduced academic achievement and cognitive abilities independent of other variables. Maternal smoking during pregnancy may therefore be a modifiable risk factor for reduced cognitive abilities later in the life of the child. Giving up smoking during pregnancy should be initiated as early as possible to reduce the impact on the child's cognitive development.

A survey of engagement and competence levels in interventions and activities in a community mental health workforce in England.

BACKGROUND: National Health Service (NHS) mental health workforce configuration is at the heart of successful delivery, and providers are advised to produce professional development strategies. Recent policy changes in England have sharpened the focus on competency based role development. We determined levels of intervention activities, engagement and competence and their influencing factors in a community-setting mental health workforce. METHODS: Using a modified questionnaire based on the Yorkshire Care Pathways Model we investigated 153 mental health staff working in Coventry and Warwickshire NHS Trust. A median score of competence was computed across 10 cluster activities. Low engagement and competence levels were examined in a logistic regression model. RESULTS: In 220 activities, Monitoring risk was the highest rate of engagement (97.6%) and Group psychological therapy/Art/Drama therapy was the lowest engagement (3.6%). The median competence level based on all activities was 3.95 (proficient). There were significant differences in the competence level among professional groups; non-qualified support group (3.00 for competent), Counsellor/Psychologist/Therapist (3.38), Occupational therapists (3.76), Nurses (4.01), Medical staff (4.05), Social workers (4.25) and Psychologists (4.62 for proficient/expert). These levels varied with activity clusters; the lowest level was for Counsellor/Psychologist/Therapist in the accommodation activity (1.44 novice/advance beginner) and the highest for Occupational therapists in personal activity (4.94 expert). In a multivariate analysis, low competence was significantly related to non-qualified community support professions, late time of obtaining first qualification, more frequencies of clinical training, and training of cognitive behavioural therapy. The associations were similar in the analysis for 10 activity clusters respectively. CONCLUSIONS: There was a reasonable competence level in the community-setting mental health workforce, but competence varied with professional groups and cluster activities. New staff and other non-qualified support professions need to receive efficient training, and the training content is more important than frequency to increase level of competence.

Imaging diagnosis--gastric pneumatosis in a cat.

Gastrointestinal foreign bodies were removed surgically from a 9-year-old Siamese cat. Two days later the cat became lethargic and started regurgitating. A degenerative leukocytosis and drop in packed cell volume were present. Gastric wall thickening with intramural gastric air was detected radiographically and sonographically. Gastric ulceration with a focal necrotic area was seen endoscopically. At surgery, the stomach wall was emphysematous. Clinical signs resolved following partial gastrectomy and medical management. Intramural gastric air with declining clinical course was a significant impetus to return to surgery.