Low-dose Initiation of Buprenorphine/naloxone for the Management of Chronic Non-cancer Pain in Patients on Long-term Opioid Therapy: A Case Series.

Background: Buprenorphine may provide superior analgesia to full opioid agonist therapy and reverse the effects of opioid-induced hyperalgesia, while having a favorable safety profile and fewer adverse effects, in chronic non-cancer pain treatment. Low-dose initiation of buprenorphine is a useful strategy for patients on long-term opioid therapy because it avoids the need for moderate opioid withdrawal required for traditional buprenorphine initiations. However, there are few published reports of low-dose initiation regimens in the setting of chronic pain. Aims: The aim of the study was to describe a case series of individuals living with chronic pain who were transitioned from long-term full opioid agonist therapy onto sublingual buprenorphine/naloxone using low-dose initiation regimens. Methods: This study is a retrospective case series that included all patients who received care at an outpatient chronic pain clinic and were scheduled for low-dose initiation of buprenorphine/naloxone between March 2020 and December 2022. Data were collected through a retrospective review of electronic medical records and results were analyzed using descriptive statistics. Results: Eighteen patients underwent transitions from their baseline opioids onto buprenorphine/naloxone using a low-dose initiation regimen. Of those patients, 17 successfully completed the initiation (94.44%), 12 experienced adverse effects during the initiation (66.67%), with only one patient requiring treatment discontinuation, and all adverse effects resolved once maintenance doses of buprenorphine/naloxone were established. The mean Clinical Global Impression-Improvement score after initiation was 2 (1-5). Conclusion: Low-dose initiation is an effective approach to transition patients with chronic non-cancer pain from long-term opioid therapy to buprenorphine/naloxone without major complications or worsening pain.

Contexte: La buprénorphine peut offrir une analgésie supérieure à celle d'un traitement par agonistes opioïdes complet et inverser les effets de l'hyperalgésie induite par les opioïdes, tout en présentant un profil d'innocuité favorable et moins d'effets indésirables dans le traitement de la douleur chronique non cancéreuse. L'initiation à faible dose de la buprénorphine est une stratégie utile pour les patients sous traitement opioïde à long terme, car elle évite le besoin de sevrage des opioïdes modéré nécessaire pour les traitements traditionnels à base de buprénorphine. Cependant, il existe peu de rapports publiés sur les régimes d'initiation à faible dose dans le cadre de la douleur chronique.Objectifs: L'objectif de cette étude était de décrire une série de cas d'individus vivant avec une douleur chronique qui sont passés d'un traitement opioïde complet à long terme à un traitement par buprénorphine sublinguale/naloxone en ayant recours à des régimes d'initiation à faible dose.Méthodes: Cette étude est une série de cas rétrospective incluant tous les patients pris en charge dans une clinique externe de traitement de la douleur chronique et pour lesquels un schéma d'initiation à faible dose de buprénorphine/naloxone a été programmé entre mars 2020 et décembre 2022. Les données ont été collectées par le biais d'un examen rétrospectif des dossiers médicaux électroniques et les résultats ont été analysés à l'aide de statistiques descriptives.Résultats: Dix-huit patients ont fait la transition des opioïdes de base à la buprénorphine/naloxone en utilisant un régime d'initiation à faible dose. Parmi ces patients, 17 ont terminé l'initiation avec succès (94,44 %), 12 ont présenté des effets indésirables pendant l'initiation (66,67 %) et un seul patient a dû interrompre son traitement. Tous les effets indésirables ont disparu une fois les doses d'entretien de buprénorphine/naloxone établies. Le score d'impression clinique globale-amélioration moyen après le début du traitement était de 2 (1-5).Conclusion: L'initiation à faible dose est une approche efficace pour faire passer les patients souffrant de douleur chronique non cancéreuse d'un traitement opioïde à long terme à la buprénorphine/naloxone sans complications majeures ni aggravation de la douleur.

Supramolecular complexation of C60 with branched polyethylene.

Fullerene C60 is a ubiquitous material for application in organic electronics and nanotechnology, due to its desirable optoelectronic properties including good molecular orbital alignment with electron-rich donor materials, as well as high and isotropic charge carrier mobility. However, C60 possesses two limitations that hinder its integration into large-scale devices: (1) poor solubility in common organic solvents leading to expensive device processing, and (2) poor optical absorbance in the visible portion of the spectrum. Covalent functionalization has long been the standard for introducing structural tunability into molecular design, but non-covalent interactions have emerged as an alternative strategy to tailor C60-based materials, offering a versatile and tuneable alternative to novel functional materials and applications. In this work, we report a straightforward non-covalent functionalization of C60 with a branched polyethylene (BPE), which occurs spontaneously in dilute chloroform solution under ambient conditions. A detailed characterization strategy, based on UV-vis spectroscopy and size-exclusion chromatography was performed to verify and investigate the structure of the C60+BPE complex. Among others, our work reveals that the supramolecular complex has an order of magnitude higher molecular weight than its C60 and BPE constituents and points towards oxidation as the driving force behind complexation. The C60+BPE complex also possesses significantly broadened optical absorbance compared to unfunctionalized C60, extending further into the visible portion of the spectrum. This non-covalent approach presents an inexpensive route to address the shortcomings of C60 for electronic applications, situating the C60+BPE complex as a promising candidate for further investigation in organic electronic devices.

Arousal affects short-term serial recall.

Arousal affects our lives in a variety of ways; it can direct our attention to what is important in our environment and help us remember it more clearly. However, it remains unclear how arousal impacts short-term memory. Here we addressed this gap in our knowledge by contrasting four hypotheses: the Arousal Hypothesis, the Priority-Binding Hypothesis, the Rehearsal Hypothesis, and the Rapid-Processing Hypothesis. To distinguish between these competing accounts, we conducted two immediate serial recall experiments in which we manipulated arousal (low-arousal words vs. high-arousal words), list composition (pure vs. mixed), and presentation rate (200 ms vs. 1,000 ms). Overall, participants were better at recalling arousing information, regardless of list type or presentation rate. Our results provide clear evidence in favor of the arousal hypothesis which suggests that arousing information benefits from biologically induced enhancements at encoding. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of Pharmacist-Led Cognitive Behavioural Therapy for Chronic Insomnia.

BACKGROUND: Chronic insomnia is a common medical condition that negatively impacts quality of life and daytime function. Access to the first-line treatment for insomnia, cognitive behavioural therapy (CBT-i), is limited. Pharmacists are well positioned to provide this service, but evidence regarding pharmacist delivered CBT-i is sparse. The aim of this study was to evaluate the effectiveness of CBT-i delivered by pharmacists practicing in an outpatient clinic setting. METHODS: This study was a retrospective chart audit of adult patients with chronic insomnia who received CBT-i from a pharmacist at one of two outpatient clinics in Canada. The primary endpoints were the differences between patient self-reported sleep diary parameters and utilization of hypnotic medications before and after CBT-i was delivered. The differences in patient reported sleep parameters were compared using Wilcoxon Signed Rank test and paired samples t-test and changes in hypnotic utilization was compared using McNemar Chi-square test. RESULTS: 183 patients were referred for CBT-i and attended an initial appointment with a pharmacist. Of these, 105 did not receive the CBT-i. This resulted in 78 patients who met the inclusion criteria. Changes in sleep diary parameters were all statistically significantly improved after patients received CBT-i, except for total sleep time. Hypnotic medication use was also reduced. At baseline, 71.8% (n=56/78) of patients were taking one or more hypnotic medications compared to 52.6% (n=41/78) after CBT-i (p=0.0003). DISCUSSION: The results of this study provide preliminary evidence that pharmacists working in an outpatient clinic setting may be able to effectively deliver CBT-i for patients with chronic insomnia. The external validity of these results is limited by the observational study design and the inclusion of pharmacists practicing in outpatient clinics, which is not the setting where most pharmacists currently practice. CONCLUSION: This observational study found improvements in sleep quality and efficiency, as well as, a reduction in hypnotic medication use, in patients who received CBT-i from pharmacists practicing in an outpatient clinic setting. Future randomized, controlled trials should evaluate the impact of CBT-i in a larger sample of patients, provided by pharmacists practicing in both outpatient clinics and community pharmacies.

Morphology and Electronic Properties of Semiconducting Polymer and Branched Polyethylene Blends.

A new strategy for influencing the solid-state morphology of conjugated polymers was developed through physical blending with a low-molecular-weight branched polyethylene. This nontoxic and low-boiling-point additive was blended with a high-charge-mobility diketopyrrolopyrrole-based conjugated polymer, and a detailed investigation of the new blended materials was performed by various characterization tools, including X-ray diffraction, UV-vis spectroscopy, and atomic force microscopy. Interestingly, the branched additive was shown to reduce the crystallinity of the conjugated polymer while promoting aggregation and phase separation in the solid state. Upon thermal removal of the olefinic additive, the thin films maintained a lower crystallinity and aggregated morphology in comparison to a nonblended polymer. The semiconducting performance of the new branched polyethylene/conjugated polymer blends was also investigated in organic field-effect transistors, which showed a stable charge mobility of around 0.3 cm2 V-1 s-1 without thermal annealing, independent of the blending ratio. Furthermore, using the new polyethylene-based additive, the concentration of a conjugated polymer required for the fabrication of organic field-effect transistor devices was reduced down to 0.05 wt %, without affecting charge transport, which represents a significant improvement compared to usual concentrations used for solution deposition. Our results demonstrate that the physical blending of a conjugated polymer with nontoxic, low-molecular-weight branched polyethylene is a promising strategy for the modification and fine-tuning of the solid-state morphology of conjugated polymers without sacrificing their charge-transport properties, thus creating new opportunities for the large-scale processing of organic semiconductors.

Vitamin and mineral supplement use in medically complex, community-living, older adults.

Individuals who take medications may benefit from using vitamin and/or mineral supplements (VMS) yet excess supplementation can lead to overuse (daily intake exceeding the tolerable upper intake level (UL)). This study assessed VMS use of medically complex, community-living, older adults. A chart review of 229 patients ≥50 years with new medication assessments between 2014 and 2017 indicated that 76.9% of patients used ≥1 VMS daily. The UL for one or more nutrients was exceeded by 39.8% of supplement users.

Assessment of Screening, Brief Intervention, and Referral to Treatment Training to Interprofessional Health-Care Students.

Substance abuse and addiction are responsible for an assortment of health and financial concerns in the United States. Tools to identify and assist at-risk persons before they develop a substance use disorder are necessary. Screening, brief intervention, and referral to treatment (SBIRT) can be utilized by health-care professionals to identify those at risk to minimize health-related complications and the potential of developing a substance use disorder. The primary objective of this study was to provide educational training sessions on SBIRT to health-care students utilizing interprofessional education activities and assess perceptions of the training sessions and activities with regard to confidence to utilize SBIRT in at-risk patients and overall student satisfaction with SBIRT instruction. The research protocol enrolled students of pharmacy, nursing, medicine, behavioral health, and physician assistant studies who received interprofessional SBIRT training. Students completed an anonymous posttraining online survey, measuring student perceptions of knowledge gained and confidence to utilize training. A total of 303 students completed the SBIRT training. Approximately 70% of students were satisfied with the training materials, instruction, quality, and experience. After training, 78% were confident that they could perform screening for substance abuse, conduct a brief intervention (80%), and when to refer to treatment (71%). A total 73% of students reported that the asynchronous online-based activity was extremely effective in increasing knowledge of the roles and responsibilities of other disciplines and providing opportunities to interact with students from other health professions. Interprofessional education-trained students from multiple health-care disciplines feel comfortable performing SBIRT to identify persons at risk for substance misuse in practice.

Student perceptions of an experiential education clinic within a pharmacy school.

BACKGROUND AND PURPOSE: Pharmacy schools would benefit from new models of experiential education. The University of Saskatchewan (Canada) recently opened a patient care clinic called the Medication Assessment Centre (MAC) as new experiential education model. The purpose of this paper is to describe the structure and function of the MAC and to report program evaluation data. EDUCATIONAL ACTIVITY AND SETTING: The MAC is a unique application of an existing experiential education model in that it is an pharmacist-run ambulatory clinic (which is common) that is physically located on campus amongst the classrooms and supervised by pharmacy faculty (which is unique). Students are all required to participate in the clinic on a regular basis, in between lectures, throughout the four years of the pharmacy program. FINDINGS: Students were invited to participate in one of five focus groups to assess the value of the experience. Transcripts were analyzed using thematic analysis, and the results identified strong satisfaction amongst students. The overall themes fell into three categories: (1) aspects that students liked, (2) aspects that students found challenging, and (3) positive impact on student learning. Previously published studies have found strong support for the MAC amongst patients and physicians. SUMMARY: Students felt that a faculty supervised experiential education clinic that is physically located within their pharmacy school was a valuable learning experience. This paper provides a description of how the MAC has been integrated into an existing pharmacy curriculum, which may be valuable to schools contemplating a similar addition to existing experiential learning.

Family physician perceptions of a medication assessment clinic located within a pharmacy school.

OBJECTIVE: To determine if the clinical services provided at a patient care clinic run by pharmacy faculty and students are valuable to family physicians. DESIGN: Paper-based postal survey. SETTING: The Medication Assessment Centre located within the College of Pharmacy and Nutrition at the University of Saskatchewan in Saskatoon. PARTICIPANTS: Family physicians who had more than 1 patient who underwent a complete assessment at the Medication Assessment Centre between April 1 and October 26, 2015, were included in the study. MAIN OUTCOME MEASURES: Family physician experience and satisfaction based on quantitative analysis of 6 Likert scale survey questions and thematic analysis of 2 open-ended survey questions. RESULTS: A total of 81 questionnaires were mailed to family physicians, with a response rate of 43.2% (n = 35). Respondents reported a very high level of support and satisfaction with the clinical pharmacist program; most (88.6%) stated that it helped them to improve the health of their patients. CONCLUSION: The family physicians who responded to the questionnaire perceived the services provided at the patient care clinic located within the pharmacy school at the University of Saskatchewan to be valuable to their practices.

A mixed methods evaluation of a patient care clinic located within a pharmacy school.

Background The Medication Assessment Center is a faculty and student run patient care clinic located within the pharmacy school at the University of Saskatchewan (Canada). It was created as a novel experiential education site for pharmacy students and to provide clinical pharmacist services for complex patients who have trouble accessing services elsewhere. Objective To determine if the clinical services provided by faculty and students at the Medication Assessment Center are valuable to patients who are referred to the program. Setting The Medication Assessment Center, which is faculty and student run patient care clinic. Method Convergent mixed methods design comprised of a retrospective patient chart audit and a paper based patient experience survey. All patients who attended at least one appointment at the Medication Assessment Center between March 1, 2014 and July 31, 2015 were included in the chart audit. All new patients who were referred between April 1, 2015 and October 26, 2015 were included in the survey. Main outcome measures Recommendations made by the pharmacist and patient experience survey indicators. Results 173 patients were included in the chart audit, which found that patients were elderly (64.8 years), highly medically complex (13.8 medications and 6.5 diagnoses each), and had a large number of recommendations made by the pharmacist to adjust drug therapy (6.2 per patient). 121 questionnaires were mailed to patients with a response rate of 66.9 % (n = 81). The survey found high levels of support and satisfaction for the program, including more than half of patients (59.2 %) who reported that their health had improved as a result of the Medication Assessment Center. Conclusion The patient care and experiential education program offered by the Medication Assessment Center provides a valuable service to patients who are referred to the clinic.

Interprofessional student-run primary health care clinics: Implications for pharmacy education in Scotland.

INTRODUCTION: Interprofessional student-run primary health care clinics have been a flagship model of health professional education in Canada for many years. The purpose of this study was to determine if there is support for implementing this educational model in the United Kingdom and to highlight the implications for pharmacy education in Scotland. METHOD: A cross-sectional postal survey of 3000 randomly selected citizens of Aberdeen city and shire, Scotland, aged 18 years and older. RESULTS: Of the 824 questionnaires that were returned (response rate 27.5%), more than half of the respondents (62.4%; n = 514) would consider accessing health care from a student-led, walk-in service. The range of services they expect to see includes general health checks (60%; n = 494), help for sexually transmitted diseases (57.5%; n = 474), weight management (56.8%; n = 468), smoking cessation (54.4%; n = 448) and drug misuse services (47.2%; n = 387). Concerns raised pertained to student ability, suitability for children and accessibility. Many comments pertained to the improvement of the current system by offering after-hours care. DISCUSSION: The positive response from the general public towards an interprofessional student-run primary health care clinic in Aberdeen suggests that this Canadian model of interdisciplinary health professional education would likely be a successful addition to the pharmacy curriculum in Scotland.

Urinary Tract Infections: Leading Initiatives in Selecting Empiric Outpatient Treatment (UTILISE).

BACKGROUND: Overuse of fluoroquinolone antibiotics is associated with outbreaks of methicillin-resistant Staphylococcus aureus and of Clostridium difficile-associated diarrhea and increasing resistance in gram-negative organisms. Over the past decade, resistance of Escherichia coli to ciprofloxacin has increased in the Regina Qu'Appelle Health Region. In August 2011, an exploratory audit of the Regina General Hospital (RGH) emergency department showed that 20% of new antibiotic orders were for fluoroquinolones, and 60% of these new fluoroquinolone orders were for ciprofloxacin. It was postulated that ciprofloxacin was predominantly prescribed for outpatients with urinary tract infection. OBJECTIVE: To develop, implement, and evaluate a best-practice algorithm for the empiric treatment of uncomplicated urinary tract infection in the RGH emergency department, as part of an educational initiative for emergency physicians. METHODS: A literature review was conducted and local antibiogram data were analyzed to establish a best-practice algorithm for treatment of uncomplicated urinary tract infection in outpatients seen in the emergency department. A chart review was conducted from January to March 2011 to establish a baseline of empiric antibiotic use. An educational strategy targeting emergency physicians described changes in antibiotic resistance patterns in the health region, principles of antimicrobial stewardship, drivers of resistance, and the results of a literature review of best practice for urinary tract infection in outpatients. A post-intervention audit was conducted from January to March 2012 to determine changes in practice. RESULTS: Comparison of results from the post-intervention audit with baseline data showed that adherence to best practice increased significantly, from 41% (39/96) before the intervention to 66% (50/76) after the intervention (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.51-5.25; p < 0.001). There was also a significant change in overall antibiotic selection (OR 0.25, 95% CI 0.11-0.58; p < 0.001). Further analysis suggested that this significant change was driven by a decrease in use of ciprofloxacin, from 32% (31/96) to 11% (8/76). CONCLUSION: Creation of a best-practice algorithm and education focused on emergency physicians significantly increased adherence to best practice and optimized antibiotic prescribing for outpatients with uncomplicated urinary tract infection by limiting overuse of fluoroquinolones, primarily ciprofloxacin.

CONTEXTE: L'utilisation abusive d'antibiotiques de la famille des fluoroquinolones est associée à des éclosions de Staphylococcus aureus résistant à la méthicilline et de diarrhée provoquée par le Clostridium difficile ainsi qu'à une augmentation de la résistance des bactéries à Gram négatif. Au cours de la dernière décennie, la résistance d'Escherichia coli à la ciprofloxacine a augmenté dans la régie régionale de la santé de Regina Qu'Appelle. En août 2011, une vérification préliminaire du service des urgences de l'Hôpital général de Régina (HGR) a montré que 20 % des nouvelles ordonnances d'antibiotiques étaient pour des fluoroquinolones et que 60 % de ces ordonnances étaient pour de la ciprofloxacine. On a émis l'hypothèse selon laquelle on prescrivait principalement la ciprofloxacine aux patients externes atteints d'une infection urinaire. OBJECTIF: Élaborer, mettre en place et évaluer un algorithme des meilleures pratiques pour le traitement empirique d'infections urinaires non compliquées au service des urgences de l'HGR dans le cadre d'une initiative de formation destinée aux urgentologues. MÉTHODES: Une revue de la littérature a été menée et les données locales d'antibiogrammes ont été analysées afin de définir un algorithme des meilleures pratiques destiné au traitement des infections urinaires non compliquées chez les patients externes rencontrés au service des urgences. Une analyse des dossiers médicaux a été effectuée de janvier à mars 2011 dans le but d'établir le traitement antibiotique empirique de référence. Une stratégie de formation destinée aux urgentologues décrivait : les changements dans les profils de résistance aux antibiotiques au sein de la régie régionale de la santé, les principes d'une gestion responsable des antimicrobiens, ainsi que les facteurs de résistance. Elle contenait aussi une revue de la littérature des meilleures pratiques pour traiter les infections urinaires chez les patients externes. Une vérification post-intervention a été menée de janvier à mars 2012 afin de déterminer les changements dans la pratique. RÉSULTATS: Une comparaison entre la vérification post-intervention et les données de référence a montré une augmentation significative de l'observance des meilleures pratiques, qui est passée de 41 % (39/96) avant l'intervention à 66 % (50/76) après l'intervention (risque relatif approché [RRA] de 2,81, intervalle de confiance [IC] à 95 % de 1,51­5,25; p < 0,001). On a aussi observé un changement significatif dans les habitudes de choix d'antibiotiques (RRA de 0,25, IC à 95 % de 0,11­0,58; p < 0,001). D'après d'autres analyses, ce changement significatif a été causé par une baisse de l'utilisation de la ciprofloxacine, qui est passée de 32 % (31/96) à 11 % (8/76). CONCLUSION: L'élaboration d'un algorithme des meilleures pratiques ainsi qu'une formation destinée aux urgentologues ont permis d'augmenter de manière significative l'observance des meilleures pratiques. Elles ont aussi permis d'optimiser la prescription d'antibiotiques aux patients externes atteints d'une infection urinaire non compliquée en réduisant l'utilisation abusive des fluoroquinolones, notamment celle de la ciprofloxacine. [Traduction par l'éditeur].

Convenient pd-catalyzed synthesis of large unimolecular star polyethylene nanoparticles.

A simplistic convenient "arm-first" catalytic synthesis method is demonstrated to render soft unimolecular star polyethylene nanoparticles. Low-dispersity polyethylene arms of controllable length and topology are first synthesized via Pd-catalyzed "living" ethylene poly-merization. The subsequent addition of norbornadiene as a unique cross-linker renders the block polymer containing a short polynorbornadiene (PNBD) sequence. Efficient and rapid catalytic cross-linking of the PNBD sequences occurs in the polymer precipitation and drying steps to give rise to star polyethylene nanoparticles. The star polymers are featured with tunable arm length and topology, high molecular weight (as high as 1770 kg mol⁻¹), high arm numbers (as high as 88), and desirable average nano-particle size (29-72 nm).

Results of a national survey on over-the-counter medicines, Part 1: Pharmacist opinion on current scheduling status.

UNLABELLED: > BACKGROUND: OTC medicines make up an important part of the community pharmacy world. As with most aspects of practice, however, hurdles exist that prevent an optimal level of care. OBJECTIVE: To gauge pharmacist agreement on the scheduling status of various OTC medicines. METHODS: Pharmacists across Canada were surveyed by mail. RESULTS: Of the 5037 surveys mailed, 2403 were returned, with 2305 being usable for analysis (response rate of 49.4%). Across 25 agents, pharmacists tended to support existing control for pharmacies (such as Nix crème rinse and minoxidil topical solution) and returning control to pharmacies for unscheduled agents (such as ranitidine 75 mg tablets and nicotine patches). CONCLUSIONS: Pharmacists generally favour tighter control of OTC agents, especially those that are unscheduled. This hopefully reflects pharmacist desire to ensure their proper selection and use.