Chronic and Sustained High-Dose Opioid Use in an Integrated Health System.

INTRODUCTION: The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain released in 2016 had led to decreases in opioid prescribing. This study sought to examine chronic and sustained high-dose prescription opioid use in an integrated health system. METHODS: A serial cross-sectional study was conducted in 2021 to estimate the annual age-adjusted prevalence and incidence of chronic and high-dose opioid use among demographically diverse noncancer adults in an integrated health system in Southern California during 2013-2020. Interrupted time-series analysis with segmented regression was conducted to estimate changes in the trends in annual rates before (2013-2015) and after (2017-2020) the 2016 guideline, treating 2016 as a wash-out period. RESULTS: Prevalence and incidence of chronic use and sustained high-dose use had started to decrease after a health system intervention program before the 2016 Centers for Disease Control and Prevention guideline release and continued to decline after the guideline. Among those with sustained high-dose use, there was a substantial decrease in persons with an average daily dosage ≥90 morphine milligram equivalent and concurrent benzodiazepine use. An accelerated decrease in prevalent chronic use after the guideline was observed (slope change: -11.1 [95% CI= -20.3, -1.9] users/10,000 person-years, p=0.03). The incidence of chronic use and sustained high-dose use continued to decrease after the guideline release but at a slower pace. CONCLUSIONS: Implementing evidence-based prescribing guidelines was associated with a decrease in chronic and sustained high-dose prescription opioid use.

Risk of Overdose with Exposure to Prescription Opioids, Benzodiazepines, and Non-benzodiazepine Sedative-Hypnotics in Adults: a Retrospective Cohort Study.

BACKGROUND: Concurrent use of benzodiazepines in opioid users has been linked to a higher risk of an emergency room visit or inpatient admission for opioid overdose and death from drug overdose. Further research is needed to confirm the findings and analyze contributing risk factors for opioid overdoses in a large commercially insured population. OBJECTIVES: To estimate the risk of opioid overdose associated with opioid users exposed to various combinations of opioid, benzodiazepine, and non-benzodiazepine sedative-hypnotic therapy. To identify other factors that are associated with increased risk for opioid overdose. DESIGN: Retrospective cohort study. PATIENTS: New start adult users of opioids, defined as naïve to opioids for 6 months, in Kaiser Permanente California regions from January 2013 through September 2017. MAIN MEASURES: Inpatient or emergency department admissions due to opioid-related overdose. KEY RESULTS: A total of 2,241,530 patients were included in this study. Patients exposed to opioids, benzodiazepines, and non-benzodiazepine sedative-hypnotics at any point during their follow-up were 60% more likely to overdose than those who were only exposed to opioids (p < 0.0001). Those exposed to opioids and benzodiazepines were 20% more likely to have an opioid-related overdose than those exposed to opioids only (p < 0.0001). Significant risk factors for opioid overdose included exposure to all three medication classes, higher opioid dosage strengths, elderly age (age ≥ 65 years), history of previous overdose, and substance use disorder. CONCLUSIONS: Results from this study demonstrate a significant increase in risk of opioid overdose in patients exposed to combinations of sedative-hypnotics with opioids compared to those only taking opioids. Findings from this study provide evidence that opioids should be avoided in combination with benzodiazepines and non-benzodiazepine sedative-hypnotics, used at the lowest dose possible, and used with caution in the elderly, those with previous history of overdose, and those with substance use disorder at baseline.

Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review.

Mental illness, deemed globally to account for 32% of years lived with a disability, generates significant impacts on workplaces. In particular, healthcare workers experience high rates of mental ill health such as burnout, stress, and depression due to workplace conditions including excessive workloads, workplace violence and bullying, which also produces negative effects on patients as well as on the happiness and wellbeing of those who remain at work. This review was undertaken to synthesize the evidence on workplace-based interventions at the organizational level promoting mental health and wellbeing among healthcare workers, to identify what has been receiving attention in this area and why, especially considering how such positive effects are produced. A search of three premier health-related databases identified 1290 articles that discussed healthcare workers, workplace interventions, and mental health. Following further examination, 46 articles were ultimately selected as meeting the criteria specifying interventions at the organizational level and combined with similar studies included in a relevant Cochrane review. The 60 chosen articles were then analyzed following a realist framework analyzing context, mechanism, and outcome. Most of the studies included in the realist review were conducted in high-income countries, and the types of organizational-level interventions studied included skills and knowledge development, leadership development, communication and team building, stress management as well as workload and time management. Common themes from the realist review highlight the importance of employee engagement in the intervention development and implementation process. The literature review also supports the recognized need for more research on mental health and happiness in low- and middle-income countries, and for studies evaluating the longer-term effects of workplace mental health promotion.

Spontaneous tempo and rhythmic entrainment in a bonobo (Pan paniscus).

The emergence of speech and music in the human species represent major evolutionary transitions that enabled the use of complex, temporally structured acoustic signals to coordinate social interaction. While the fundamental capacity for temporal coordination with complex acoustic signals has been shown in a few distantly related species, the extent to which nonhuman primates exhibit sensitivity to auditory rhythms remains controversial. In Experiment 1, we assessed spontaneous motor tempo and tempo matching in a bonobo (Pan paniscus), in the context of a social drumming interaction. In Experiment 2, the bonobo spontaneously entrained and synchronized her drum strikes within a range around her spontaneous motor tempo. Our results are consistent with the hypothesis that the evolution of acoustic communication builds upon fundamental neurodynamic mechanisms that can be found in a wide range of species, and are recruited for social interactions.

Evaluation of Multidrug Therapy With Azithromycin, Rifampin, and Ethambutol for the Treatment of Mycobacterium avium subsp avium in Ring-neck Doves (Streptopelia risoria): An Uncontrolled Clinical Study.

An uncontrolled clinical study was conducted to evaluate the efficacy of a multidrug protocol in 16 ring-neck doves ( Streptopelia risoria ) from a flock naturally infected with Mycobacterium avium subsp avium. The doves were considered infected on the basis of a high prevalence of infection in a group of 29 birds that were euthanatized from the same flock and clinical signs and pathologic results consistent with infection in the remaining birds. All birds were treated with azithromycin (43 mg/kg), rifampin (45 mg/kg), and ethambutol (30 mg/kg) administered orally once daily for 180 days. Five birds died during treatment and were confirmed positive for mycobacteriosis on postmortem examination. Of the remaining 11 birds, infection and disease were present in 9 (81.8%) at the end of the treatment. Postmortem investigation showed that 2 mycobacterial isolates were resistant to ethambutol, intermediately sensitive to rifampin, and sensitive to azithromycin. Microscopic examination of liver sections equivalent of those that would be taken for biopsy showed that biopsy as a method of monitoring birds for treatment success had poor sensitivity. Toxicity associated with drug therapy was not observed in these doves nor in 6 outwardly healthy ring-neck doves exposed to the same treatment. The results of this study showed that this protocol of azithromycin, rifampin, and ethambutol has poor efficacy when administered for 180 days for treatment of doves infected with M avium subsp avium.

Text messaging as adjunct to community-based weight management program.

Increasing obesity rates are still a public health priority. The primary aim of this study was to evaluate the effect of tailored text messages on body weight change in overweight and obese adults in a community-based weight management program. A secondary aim was to detect behavioral changes in the same population. The study design was quasi-experimental with pretest and posttest analysis, conducted over 12 weeks. A total of 28 participants were included in the analysis. Body weight, eating behaviors, exercise and nutrition self-efficacy, attitude toward mobile technology, social support, and physical activity were assessed at baseline and at 12 weeks. Text messages were sent biweekly to the intervention but not to the control group. At 12 weeks, the intervention group had lost significant weight as compared with the control group. There was a trend toward an improvement in eating behaviors, exercise, and nutrition self-efficacy in the intervention group, with no significant difference between groups. A total of 79% of participants stated that text messages helped in adopting healthy behaviors. Tailored text messages appear to enhance weight loss in a weight management program at a community setting. Large-scale and long-term intervention studies are needed to confirm these findings.

Complete genome sequence of avian bornavirus genotype 1 from a Macaw with proventricular dilatation disease.

Avian bornaviruses (ABV) were first detected and described in 2008. They are the etiologic agents of proventricular dilatation disease (PDD), a frequently fatal neurologic disease of captive parrots. Seven ABV genogroups have been identified worldwide from a variety of sources, and that number may increase as surveillance for novel bornaviruses continues. Here, we report the first complete sequence of a genogroup 1 avian bornavirus (ABV1).

Proventricular dilatation disease in cockatiels (Nymphicus hollandicus) after infection with a genotype 2 avian bornavirus.

An isolate of genotype 2 avian bornavirus (ABV) was recovered from a cockatiel (Nymphicus hollandicus) that was euthanatized for an unrelated lesion and showing no clinical evidence of proventricular dilatation disease (PDD). On histopathologic examination, mild inflammatory lesions were present in the heart and brain, but gastrointestinal lesions characteristic of classic PDD were not observed. To investigate if this ABV2 isolate had reduced virulence, the virus was propagated in duck embryo fibroblasts and inoculated into 2 adult cockatiels by the oral and intramuscular routes. One bird developed clinical signs on day 33 and was euthanatized on day 36. The second challenged bird developed clinical signs on day 41 and was euthanatized on day 45. At necropsy, the proventriculus of both birds was slightly enlarged. Histopathologic examination showed lesions typical of PDD in the brain, spinal cord, heart, adrenal gland, and intestine. A control, uninoculated cockatiel was apparently healthy when euthanatized on day 50. These results show that ABV2 is now the second ABV genotype to be formally shown to cause PDD.

The isolation, pathogenesis, diagnosis, transmission, and control of avian bornavirus and proventricular dilatation disease.

Proventricular dilatation disease (PDD) is a common infectious neurologic disease of birds comprising a dilatation of the proventriculus by ingested food as a result of defects in intestinal motility, which affects more than 50 species of psittacines, and is also known as Macaw wasting disease, neuropathic ganglioneuritis, or lymphoplasmacytic ganglioneuritis. Definitive diagnosis of PDD has been problematic due to the inconsistent distribution of lesions. Since its discovery, avian bornavirus (ABV) has been successfully cultured from the brains of psittacines diagnosed with PDD, providing a source of antigen for serologic assays and nucleic acid for molecular assays. This article provides evidence that ABV is the etiologic agent of PDD. Recent findings on the transmission, epidemiology, pathogenesis, diagnosis, and control of ABV infection and PDD are also reviewed.

Molecular characterization of the cloacal microbiota of wild and captive parrots.

The gastrointestinal microbiota plays a fundamental role in health and disease. Only limited data are available about the composition of the intestinal microbiota of captive animals compared to those of wild animals. The aim of the present study was to characterize the cloacal microbiota of apparently healthy wild and captive parrots. A total of 16 parrots, 8 wild and 8 captive, belonging to 3 different species, were used in this study. Cloacal material was collected via cloacal swabbing. DNA was extracted and 16S rRNA genes were amplified using universal bacterial primers. Constructed 16S rRNA gene clone libraries were compared between groups. A total of 518 clones were analyzed, and 49 operational taxonomic units (OTUs) were identified. The OTUs were classified in 4 bacterial phyla: Firmicutes (72.9%), Proteobacteria (14.9%), Actinobacteria (12%), and Bacteroidetes (0.2%). Bacterial diversity was significantly lower in wild birds than in captive birds. Principal component analysis based on the Unifrac distance metric indicated that the cloacal microbiota differed between wild and captive parrots. Staphylococcus saprophyticus was significantly more abundant in wild birds, while Escherichia coli was significantly more abundant in captive birds. In conclusion, wild and captive parrots appear to have differences in the composition of their cloacal bacterial microbiota. The clinical significance of these differences remains to be determined.

Use of avian bornavirus isolates to induce proventricular dilatation disease in conures.

Avian bornavirus (ABV) is a newly discovered member of the family Bornaviridae that has been associated with the development of a lethal neurologic syndrome in birds, termed proventricular dilatation disease (PDD). We successfully isolated and characterized ABV from the brains of 8 birds with confirmed PDD. One isolate was passed 6 times in duck embryo fibroblasts, and the infected cells were then injected intramuscularly into 2 healthy Patagonian conures (Cyanoliseus patagonis). Clinical PDD developed in both birds by 66 days postinfection. PDD was confirmed by necropsy and histopathologic examination. Reverse transcription-PCR showed that the inoculated ABV was in the brains of the 2 infected birds. A control bird that received uninfected tissue culture cells remained healthy until it was euthanized at 77 days. Necropsy and histopathologic examinations showed no abnormalities; PCR did not indicate ABV in its brain tissues.

The diagnosis of proventricular dilatation disease: use of a Western blot assay to detect antibodies against avian Borna virus.

Avian Borna virus (ABV) has recently been shown to be the causal agent of proventricular dilatation disease (PDD) a lethal neurologic disease of captive psittacines and other birds. An immunoblot assay was used to detect the presence of antibodies against avian Borna virus in the serum of affected birds. A lysate from ABV-infected duck embryo fibroblasts served as a source of antigen. The assay was used to test for the presence of antibodies to ABV in 117 birds. Thirty of these birds had biopsy or necropsy-confirmed proventricular dilatation disease (PDD), while the remaining 87 birds were apparently healthy or were suffering from diseases other than PDD. Sera from 27 of the 30 PDD cases (90%) contained antibodies to ABV. Seventy-three (84%) of the apparently "healthy" birds were seronegative. Additionally, sera from seven macaws and one parrot trapped in the Peruvian Amazon were seronegative. Positive sera recognized the bornaviral nucleoprotein (N-protein). While the presence of antibodies to ABV largely corresponded with the development of clinical PDD, 14 apparently healthy normal birds possessed detectable antibodies to ABV. The existence of a carrier state was confirmed when 13 of 15 apparently healthy cockatiels were shown by PCR to have detectable ABV RNA in their feces. Western blot assays may be of significant assistance in diagnosing proventricular dilatation disease. Many apparently healthy birds may however be seronegative while, at the same time, shedding ABV in their feces.

Critical reflections on culture in nursing.

The purpose of this paper is to raise awareness of a view of culture as a sociopolitical construction, and to explore implications for incorporating this view into U.S. nursing education and practice. Current definitions of culture, cultural diversity, and cultural competence are examined to highlight ways in which a traditional, essentialist view is reflected. Examples of an alternative, constructivist view are provided through discussion and in a series of questions. These questions serve as the basis for considering new approaches in U.S. nursing education and health care based on view of culture as a dynamic and ever-changing sociopolitical construction.