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BACKGROUND: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies. METHODS: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups. RESULTS: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently). CONCLUSIONS: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.
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Introduction: To expand access to naloxone, the state of Illinois implemented a standing order allowing registered pharmacies to dispense the drug without an individual prescription. To participate under the standing order, pharmacies were required to opt in through a formal registration process. In our study we aimed to evaluate the availability and price of naloxone at registered pharmacies. Methods: This was a prospective, de-identified, cross-sectional telephone survey. Trained interviewers posed as potential customers and used a standardized script to determine the availability of naloxone between February-December, 2019. The primary outcome was defined as a pharmacy indicating it carried naloxone, currently had naloxone in stock, and was able to dispense it without an individual prescription. Results: Of 948 registered pharmacies, 886 (93.5%) were successfully contacted. Of those, 792 (83.4%) carried naloxone, 659 (74.4%) had naloxone in stock, and 472 (53.3%) allowed purchase without a prescription. Naloxone nasal spray (86.4%) was the formulation most commonly stocked. Chain pharmacies were more likely to carry naloxone (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 1.97-5.01, P < 0.01) and have naloxone in stock (aOR 2.72, 95% CI 1.76-4.20, P < 0.01), but no more likely to dispense it without a prescription. Pharmacies in higher population areas (aOR 0.99, 95% CI 0.99-0.99, P < 0.05) and rural areas adjacent to metropolitan areas (aOR 0.5, 95% CI 025-0.98, P < 0.05) were less likely to have naloxone available without a prescription. Associations of naloxone availability based on other urbanicity designations, overdose count, and overdose rate were not significant. Conclusion: Among pharmacies in Illinois that formally registered to dispense naloxone without a prescription, the availability of naloxone remains limited. Additional interventions may be needed to maximize the potential impact of a statewide standing order.
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Naloxona , Antagonistas de Narcóticos , Farmacias , Naloxona/provisión & distribución , Naloxona/uso terapéutico , Humanos , Estudios Transversales , Estudios Prospectivos , Illinois , Antagonistas de Narcóticos/provisión & distribución , Antagonistas de Narcóticos/uso terapéutico , Farmacias/estadística & datos numéricos , Órdenes Permanentes , Accesibilidad a los Servicios de Salud , Masculino , Femenino , Sobredosis de Droga/tratamiento farmacológicoRESUMEN
Airborne transmission of SARS-CoV-2 aerosol remains contentious. Importantly, whether cough or breath-generated bioaerosols can harbor viable and replicating virus remains largely unclarified. We performed size-fractionated aerosol sampling (Andersen cascade impactor) and evaluated viral culturability in human cell lines (infectiousness), viral genetics, and host immunity in ambulatory participants with COVID-19. Sixty-one percent (27/44) and 50% (22/44) of participants emitted variant-specific culture-positive aerosols <10µm and <5µm, respectively, for up to 9 days after symptom onset. Aerosol culturability is significantly associated with lower neutralizing antibody titers, and suppression of transcriptomic pathways related to innate immunity and the humoral response. A nasopharyngeal Ct <17 rules-in ~40% of aerosol culture-positives and identifies those who are probably highly infectious. A parsimonious three transcript blood-based biosignature is highly predictive of infectious aerosol generation (PPV > 95%). There is considerable heterogeneity in potential infectiousness i.e., only 29% of participants were probably highly infectious (produced culture-positive aerosols <5µm at ~6 days after symptom onset). These data, which comprehensively confirm variant-specific culturable SARS-CoV-2 in aerosol, inform the targeting of transmission-related interventions and public health containment strategies emphasizing improved ventilation.
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COVID-19 , SARS-CoV-2 , Humanos , Cinética , Aerosoles y Gotitas RespiratoriasRESUMEN
BACKGROUND: One still encounters opinion that hearing loss with high-pitch notched audiogram is invariably due to noise-induced hearing loss. This paper tests this misapprehension. METHODS: A study was conducted of patients identified in a prospective manner with notched audiograms but no history of noise exposure occurring in an otolaryngological practice over a 20-year period. RESULTS: A cohort of 26 hearing loss patients, in whom notched audiograms were not associated with historical evidence of noise exposure, was documented. CONCLUSION: The findings confirm that a notched audiogram is not pathognomonic of noise-induced hearing loss.
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Sordera , Pérdida Auditiva Provocada por Ruido , Humanos , Pérdida Auditiva Provocada por Ruido/diagnóstico , Pérdida Auditiva Provocada por Ruido/etiología , Estudios Prospectivos , Umbral Auditivo , Pruebas AuditivasRESUMEN
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
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Acetaminofén , Dolor Agudo , Adulto , Humanos , Acetaminofén/uso terapéutico , Ibuprofeno/uso terapéutico , Oxicodona/uso terapéutico , Metaanálisis en Red , Antiinflamatorios no Esteroideos/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Analgésicos Opioides/uso terapéutico , Extracción Dental/efectos adversos , Dolor Agudo/tratamiento farmacológico , Dolor Agudo/etiologíaRESUMEN
OBJECTIVES: Frontal sinus obliteration is often performed using fat, autologous bone or a range of synthetic materials. This paper reports the long-term clinical and radiological outcomes of frontal sinus obliteration using beta-tricalcium phosphate putty. METHODS: A retrospective audit was performed of patients who underwent frontal sinus obliteration with beta-tricalcium phosphate putty. Patient-, disease- and procedure-related data were collected. Pre- and post-operative computed tomography scans were reviewed to assess bone integration. RESULTS: Four patients underwent frontal sinus obliteration using beta-tricalcium phosphate putty for treatment of a cerebrospinal leak, mucocele and recalcitrant frontal sinusitis. All patients had disease resolution, with no intra- or post-operative complications reported in the 16.5-month follow up. Post-operative computed tomography scans confirmed native bone obliteration of the frontonasal ducts in all patients. CONCLUSION: Beta-tricalcium phosphate putty is a safe and effective option for bone obliteration of the frontal sinus in a range of pathologies, including cerebrospinal fluid leak.
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Seno Frontal , Sinusitis Frontal , Humanos , Seno Frontal/patología , Estudios de Seguimiento , Estudios Retrospectivos , Sinusitis Frontal/patología , Sinusitis Frontal/cirugíaRESUMEN
Information on how forage species influence sediment and nutrient transport in runoff is required for limiting non-point source pollution from broiler litter applications. In this study, we examined the effects of five forage species (eastern gamagrass [Tripsacum dactyloides (L.) L.], Kernza [Thinopyrum intermedium (Host) Barkworth & D.R. Dewey], silphium [Silphium integrifolium Michx.], switchgrass [Panicum virgatum L.], and winter wheat [Triticum aestivum L.]) on runoff nutrient losses from broiler litter-amended (5.6 Mg ha-1 ) and non-amended plots (control) following four simulated rainfall (5 cm h-1 ) events that were applied to these plots in late spring and early fall of 2019 and 2021. Runoff collected for 30 min was analyzed for total suspended solids (TSS) and nutrients (total organic carbon [TOC], soluble reactive phosphorus [SRP], total dissolved phosphorus [TDP], total phosphorus [TP], total nitrogen [TN], ammonium-nitrogen [NH4 -N], and nitrate-nitrogen [NO3 -N]). Total sediment and nutrient losses increased 5- to 19-fold following litter application for all species, which reduced to background levels during fall rainfall events. Across the four simulated rainfall events, switchgrass resulted in lower cumulative losses of TSS, TOC, SRP, TDP, TP, and NO3 -N than gamagrass and wheat but did not differ from Kernza and silphium for litter-amended treatments. The performance of newly introduced perennial crops (Kernza and silphium) was similar or better than that of gamagrass in terms of cumulative runoff sediment and nutrient losses. Results show high potential for Kernza, silphium, and switchgrass to improve water quality when used in forage-vegetative filter strip systems.
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Pollos , Panicum , Animales , Estiércol , Nitrógeno/análisis , Nutrientes , Triticum , Fósforo , Lluvia , Proteínas de Unión al ADN , Movimientos del AguaRESUMEN
Background: Advancements in research and legislation have improved emergency provider ability to treat opioid use disorder (OUD), but dissemination into rural emergency departments (EDs) is limited. Project Extension for Community Healthcare Outcomes (ECHO) allows community generalists to learn from specialists through telementoring. We aimed to use ECHO to facilitate knowledge translation, increase confidence, and change behavior of rural ED providers treating patients with OUD. Methods: Stakeholder interviews were conducted with rural ED providers. A group of ED addiction experts created an ECHO curriculum with eight OUD topics. ED health professionals were recruited and completed pre/post surveys centered around knowledge and comfort with treating OUD in the ED, with focus on clinical practice and stigma. Following the ECHO model, sessions included a 20-min didactic followed by two cases presented by participants, with discussion facilitated by faculty. Results: Twenty-seven participants registered; seven attended ≥75% of sessions and completed both surveys. Of the seven, three were physicians, two advanced practice providers, one nurse, and one clinical pharmacist. Eight 1-hour sessions were conducted in two cohorts between January and December 2021. On a 5-point Likert scale, respondents on average agreed with questions evaluating acceptability (mean ± SD 3.96 ± 0.64), appropriateness (mean ± SD 4.18 ± 1.18), and feasibility (mean ± SD 4.00 ± 1.17). Participants had a 1.09-point increase (paired t-test = 2.43, p = 0.05) on 7-point Likert-scale questions measuring self-efficacy and a 0.13-point change (paired t-test = 2.64, p = 0.04) on 4-point Likert scale questions measuring stigmatizing attitudes (reduction of attitudes). A total of 71% (5/7) reported changes in clinical practice and 57% (4/7) in departmental protocols after participation. Conclusions: Our ED OUD ECHO course successfully created a model for rural ED providers to learn from ED addiction experts. It was well received and impacted self-reported provider stigmatizing attitudes, patient-facing behavior, and departmental initiatives. Recruitment was challenging and participation was limited. Future efforts will target maximizing recruitment.
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OBJECTIVES: Infant mental health (IMH), an area which focuses on the social and emotional development of infants in the context of the parent-infant relationship, has become an increasingly prominent field of both research and clinical practice worldwide. IMH network groups are initiatives which aim to facilitate continuous learning in the IMH approach, provide an opportunity for case discussion and encourage reflective practice. This study aimed to explore the experiences of staff working within an adult mental health (AMH) service and their participation in a perinatal IMH network group (PIMH-NG). METHODS: This study had a qualitative research design and the data were collected using a focus group methodology. Participants were recruited from a PIMH-NG which aimed to provide staff working within an AMH setting with the opportunity for continuous development of IMH knowledge. The data were analysed using thematic analysis. RESULTS: The data gathered from the focus group indicated that staff participating in a PIMH-NG enhanced their clinical skill, reflective practice and supported the dissemination of IMH knowledge throughout their respective teams. The PIMH-NG facilitated this work by providing the opportunity for continuous learning, reflective group discussion and ongoing peer support. CONCLUSIONS: The findings of this study indicate that incorporating elements of an IMH model into AMH services can be beneficial for staff, service users and overall service delivery and development. These findings may be used to develop the structure and content of future network groups of this nature.
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Watershed and pasture health is a transdisciplinary concern and crucial to promoting sustainable practices. The aim of this study is to identify effective systems-level conservation pasture management practices in a longitudinal study following 14 years of consistent management by i) teasing apart complex relationships between multivariate water and soil quality using principal component analysis (PCA); and ii) identifying interactions among variables that contribute most to watershed health within catchments using partial least squares-path modeling (PLS-PM) based on five treatments: hayed (H), continuously grazed (CG), rotationally grazed (R), rotationally grazed with an unfertilized buffer strip (RB), and rotationally grazed with an unfertilized fenced riparian buffer (RBR). Over 14 years, H and RBR systems had greater watershed health based on runoff water quality parameters. Therefore, management systems that keep forage heights >10-cm, have less frequent vegetative removal, and riparian filter strips promote watershed health. Of the over 20 runoff variables measured over 14 study years, only electrical conductivity and annual total suspended solid loads constructed a significant water quality PLS-PM model. Water quality was positively influenced by pasture management and precipitation, with long-term pasture management driving runoff parameters and water quality. Overall, animal grazing days was not only related to grazing intensity, but to animal manure inputs and soil compaction, and adversely related to watershed health. Study results denote that best management strategies such as rotational grazing and riparian buffer strips prevent pasture system degradation and maintain carrying capacity while reducing anthropogenic pressure on soil and water systems.
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Estiércol , Suelo , Animales , Conservación de los Recursos Naturales , Estudios Longitudinales , Calidad del AguaRESUMEN
The emergence of the COVID-19 viral pandemic has generated a renewed interest in pharmacologic agents that target the renin angiotensin system (RAS). Angiotensin-converting enzyme 1 (ACE1) inhibitors decrease the synthesis of angiotensin II (Ang II) from its precursor angiotensin I and inhibit the breakdown of bradykinin, while Ang II receptor blockers antagonize the action of Ang II at the receptor level downstream. The actions of both classes of drugs lead to vasodilation, a blunting of sympathetic drive and a reduction in aldosterone release, all beneficial effects in hypertension and congestive heart failure. ACE2 cleaves the vasoconstrictor Ang II to produce the anti-inflammatory cytoprotective angiotensin 1-7 (Ang 1-7) peptide, which functions through the G protein-coupled receptor MAS to counteract the pathophysiologic effects induced by Ang II via its receptors, including vasoconstriction, inflammation, hypercoagulation, and fibrosis. SARS-CoV-2 enters human cells by binding ACE2 on the cell surface, decreases ACE2 activity, competes for ACE2 receptor-binding sites, and shifts the RAS toward an overexpression of Ang II, accounting for many of the deleterious effects of the virus. Thus, there is great interest in developing recombinant ACE2 as a therapeutic for prevention or treatment of COVID-19. Notably, ACE2 is highly expressed in the oral cavity, and saliva and dorsum of the tongue are major reservoirs of SARS-CoV-2. Cost-effective methods to debulk the virus in the oral cavity may aid in the prevention of viral spread. Here we review the pharmacology of targeted small molecule inhibitors of the RAS and discuss novel approaches to employing ACE2 as a therapeutic for COVID-19.
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COVID-19 , Antagonistas de Receptores de Angiotensina , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Humanos , Sistema Renina-Angiotensina , SARS-CoV-2RESUMEN
INTRODUCTION: Opioid overdose education and naloxone distribution (OEND) for use by laypersons are safe and effective at preventing deaths from opioid overdose, but emergency department (ED) implementation is challenging. Curricula addressing OEND could enable students to serve in value-added roles on the clinical team, overcome challenges of naloxone distribution, and improve patient care. METHODS: We created a 1-hour didactic session on opioid use disorder and OEND for first-year medical students in the emergency medicine elective. During two clinical shifts, students used this knowledge to perform screenings to identify patients at high risk of overdose. If a patient screened positive, students performed patient education and then notified the physician, who ordered a naloxone kit. RESULTS: Thirty students received the didactic and conducted screening shifts. Of 147 patients screened, 40% (n = 59) were positive for naloxone eligibility, 21% (n = 31) reported that someone close to them used opioids, 18% (n = 26) had witnessed an opioid overdose, 12% (n = 17) had previously overdosed themselves, and 12% (n = 18) previously knew what naloxone was. Fifty-nine naloxone kits were distributed over the 3-month pilot versus 13 naloxone prescriptions for patients discharged from the ED the prior year. DISCUSSION: Through didactic training and structured patient engagement, medical students gained knowledge of and hands-on experience with addiction medicine, discussed sensitive topics with patients, and identified a high volume of patients eligible to receive naloxone. Medical student screening for OEND in ED patients is feasible and adds significant value to the clinical team.
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Naloxona , Estudiantes de Medicina , Analgésicos Opioides , Servicio de Urgencia en Hospital , Humanos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Epidemia de OpioidesAsunto(s)
COVID-19 , Pandemias , Procedimientos Quirúrgicos Electivos , Humanos , Control de Infecciones , SARS-CoV-2RESUMEN
PURPOSE: Opioid overdose education and naloxone distribution (OEND) for use by laypersons has been shown to be safe and effective, but implementation in the emergency department (ED) setting is challenging. Recent literature has shown a discouragingly low rate of obtainment of naloxone that is prescribed in the ED setting. We conducted a study to evaluate the feasibility of point-of-care (POC) distribution of naloxone in an ED, hypothesizing a rate of obtainment higher than prescription fill rates reported in previous studies. SUMMARY: A multidisciplinary team of experts, including pharmacists, physicians, nurses, and case management professionals used an iterative process to develop a protocol for POC OEND in the ED. The protocol includes 5 steps: (1) patient screening, (2) order placement in the electronic health record (EHR), (3) a patient training video, (4) dispensing of naloxone kit, and (5) written discharge instructions. The naloxone kits were assembled, labeled to meet requirements for a prescription, and stored in an automated dispensing cabinet. Two pharmacists, 30 attending physicians, 65 resident physicians, and 108 nurses were trained. In 8 months, 134 orders for take-home naloxone were entered and 117 naloxone kits were dispensed, resulting in an obtainment rate of 87.3%. The indication for take-home naloxone kit was heroin use for 61 patients (92.4%). CONCLUSION: POC naloxone distribution is feasible and yielded a rate of obtainment significantly higher than previous studies in which naloxone was prescribed. POC distribution can be replicated at other hospitals with low rates of obtainment.
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Sobredosis de Droga , Trastornos Relacionados con Opioides , Analgésicos Opioides/uso terapéutico , Sobredosis de Droga/tratamiento farmacológico , Sobredosis de Droga/epidemiología , Servicio de Urgencia en Hospital , Humanos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Proyectos Piloto , Sistemas de Atención de PuntoRESUMEN
The emergency department (ED) serves as the main source of care for patients who are victims of interpersonal violence. As a result, emergency physicians across the nation are at the forefront of delivering care and determining dispositions for many at-risk patients in a dynamic healthcare environment. In the majority of cases, survivors of interpersonal violence are treated and discharged based on the physical implications of the injury without consideration for risk of reinjury and the structural drivers that may be at play. Some exceptions may exist at institutions with hospital-based violence intervention programs (HVIPs). At these institutions, disposition decisions often include consideration of a patient's risk for repeat exposure to violence. Ideally, HVIP services would be available to all survivors of interpersonal violence, but a variety of current constraints limit availability. Here we offer a scoping review of HVIPs and our perspective on how risk-stratification could help emergency physicians determine which patients will benefit most from HVIP services and potentially reduce re-injury secondary to interpersonal violence.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Armas de Fuego , Medición de Riesgo/métodos , Población Urbana/estadística & datos numéricos , Violencia/estadística & datos numéricos , Humanos , SobrevivientesRESUMEN
Rye is high in nonstarch polysaccharides (NSP), a complex carbohydrate which cannot be digested by poultry as they lack the endogenous enzymes to do so. Exogenous carbohydrases must therefore be supplemented to avoid the antinutritional effects associated with a high NSP diet. The objectives of the present study were to evaluate the effects of a rye-based diet with and without supplementation of a Bacillus direct-fed microbial (DFM) on body weight, bone mineralization, and leaky gut, as well as its role on influencing serum concentrations of peptide YY (PPY) and the ammonia concentration in turkey manure. Two independent trials were conducted. In each experiment, day-of-hatch female turkey poults were neck tagged and randomly assigned to either a control rye-based diet or a rye-based diet supplemented with the DFM (n = 25 birds/group). At 10 days-of-age, poults in both groups were administered with an appropriate dose of fluorescein isothiocyanate-dextran (FITC-d) by oral gavage. One hour later, all poults were euthanized. Blood was collected to evaluate serum FITC-d and PPY concentrations. Furthermore, in Trial 2 only, both tibias were removed for assessment of bone parameters, and turkey manure was collected to evaluate physicochemical analysis. In both trials, poults treated with the DFM showed a significant increase (P < 0.05) in body weight and body weight gain as compared with control nontreated poults. Poults that received the DFM also had a significant reduction in serum levels of PPY and FITC-d when compared with control nontreated poults. In Trial 2, turkeys treated with the DFM had a substantial increase in tibia strength, tibia diameter, total ash, calcium, and phosphorus when compared with control nontreated turkeys. Their manure was also shown to have a significant reduction in the concentration of ammonia. This is the first report of a commercial DFM reducing the concentration of this compound in turkey manure. In summary, the results of the present study confirm that turkeys fed with a rye-based diet have a significant increase in gut permeability, a reduced body weight, and decreased bone mineralization when compared with turkeys fed with the DFM. Turkeys that received the rye-based diet supplemented with the Bacillus-DFM also had a significant reduction in the serum concentration of PPY when compared with control turkeys. This finding suggests a possible prebiotic effect of rye, warranting future studies to test this effect. Further studies to evaluate the microbiota diversity, as well as the concentration of ceca short-chain fatty acids, are also necessary to confirm the reliability of PPY as a potential metabolomic biomarker in poultry.
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Amoníaco , Bacillus , Calcificación Fisiológica , Péptido YY , Probióticos , Pavos , Amoníaco/metabolismo , Alimentación Animal/análisis , Animales , Animales Recién Nacidos , Calcificación Fisiológica/fisiología , Dieta/veterinaria , Femenino , Péptido YY/sangre , Distribución Aleatoria , Reproducibilidad de los Resultados , SecaleRESUMEN
Postsurgical dental pain is mainly driven by inflammation, particularly through the generation of prostaglandins via the cyclooxygenase system. Thus, it is no surprise that numerous randomized placebo-controlled trials studying acute pain following the surgical extraction of impacted third molars have demonstrated the remarkable efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, etodolac, diclofenac, and ketorolac in this prototypic condition of acute inflammatory pain. Combining an optimal dose of an NSAID with an appropriate dose of acetaminophen appears to further enhance analgesic efficacy and potentially reduce the need for opioids. In addition to being on average inferior to NSAIDs as analgesics in postsurgical dental pain, opioids produce a higher incidence of side effects in dental outpatients, including dizziness, drowsiness, psychomotor impairment, nausea/vomiting, and constipation. Unused opioids are also subject to misuse and diversion, and they may cause addiction. Despite these risks, some dental surgical outpatients may benefit from a 1- or 2-d course of opioids added to their NSAID regimen. NSAID use may carry significant risks in certain patient populations, in which a short course of an acetaminophen/opioid combination may provide a more favorable benefit versus risk ratio than an NSAID regimen.
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Analgésicos Opioides , Dolor Postoperatorio/tratamiento farmacológico , Preparaciones Farmacéuticas , Analgésicos Opioides/efectos adversos , Antiinflamatorios no Esteroideos/efectos adversos , Diclofenaco , HumanosRESUMEN
Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.
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Sobredosis de Droga/prevención & control , Servicio de Urgencia en Hospital/legislación & jurisprudencia , Implementación de Plan de Salud/legislación & jurisprudencia , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/prevención & control , Alta del Paciente , Chicago , Humanos , Gobierno EstatalRESUMEN
The path signature is a means of feature generation that can encode nonlinear interactions in data in addition to the usual linear terms. It provides interpretable features and its output is a fixed length vector irrespective of the number of input points or their sample times. In this paper we use the path signature to provide features for identifying people whose diagnosis subsequently converts to Alzheimer's disease. In two separate classification tasks we distinguish converters from 1) healthy individuals, and 2) individuals with mild cognitive impairment. The data used are time-ordered measurements of the whole brain, ventricles and hippocampus from the Alzheimer's Disease Neuroimaging Initiative (ADNI). We find two nonlinear interactions which are predictive in both cases. The first interaction is change of hippocampal volume with time, and the second is a change of hippocampal volume relative to the volume of the whole brain. While hippocampal and brain volume changes are well known in Alzheimer's disease, we demonstrate the power of the path signature in their identification and analysis without manual feature selection. Sequential data is becoming increasingly available as monitoring technology is applied, and the path signature method is shown to be a useful tool in the processing of this data.