Opioid use in older orthopedic rehabilitation inpatients: a retrospective study.

BACKGROUND: While there is much evidence about pain management for orthopedic patients in the immediate perioperative setting, little is known about how opioids are used during inpatient rehabilitation, particularly in older adults. A safe upper limit of 50 mg oral morphine equivalents (OME) is frequently cited in guidelines. AIM: The aim of this study was to characterize the dosing of opioids in an older adult population undergoing inpatient orthopedic rehabilitation (IOR). DESIGN: Retrospective observational study. SETTING: Inpatient units at an academic rehabilitation hospital in Toronto, Canada. POPULATION: All adults aged ≥50 years old admitted for orthopedic rehabilitation between November 2019 and June 2021 following acute care admissions for either a surgical or non-surgical orthopedic indication. METHODS: Participants were divided into groups of prior opioids users, new opioids users, and opioid non-users during IOR. Demographic, clinical, and medication administration data were collected through the electronic health record and manual chart review. Average daily opioid dose for the first seven days of each stay was characterized using OME. Linear regression was used to assess for variables independently associated with opioid dose. RESULTS: A total of 643 patients undergoing orthopedic rehabilitation were included: 125 (19.4%) were prior opioid users, 416 (64.7%) were new opioid users, and 102 (15.9%) were non-users, with median age respectively of 72, 79, and 83. Median daily OME over the first week for prior users was 30.3 and for new users was 6.9. Opioid dose was inversely associated with age and admission for a non-surgical indication; it was positively associated with reported pain (as defined by day 3 pain score) and admission for knee replacement. CONCLUSIONS: Opioids are frequently but heterogeneously used in older adults undergoing IOR. Median OME use in this cohort of older adults was substantially lower than the 50 OME threshold suggested in guidelines, particularly for new opioid users. CLINICAL REHABILITATION IMPACT: Older adults require much lower opioid doses than younger patients. Pain management in older orthopedic rehabilitation inpatients is distinct from the perioperative setting and deserves tailored guidance, with a focus on using the lowest effective dose.

Patient outcomes related to receiving care on a dedicated Acute Care for Elders (ACE) unit versus with an ACE order set.

BACKGROUND: The Acute Care for Elders (ACE) unit model of care aims to reduce common complications of hospitalization in older adults through early involvement of allied health providers, changes to the care environment, elder-friendly care protocols, and proactive discharge planning. Our hospital established a dedicated 28-bed medical ACE unit. Because of capacity limitations, the number of eligible older medical patients often exceeds the available number of beds. Thus, some ACE unit-eligible patients are instead admitted to other medical or surgical units for their medical care. These "bed-spaced" ACE patients receive care by the same general internists and ACE order set that ACE unit patients are cared under. We sought to compare the health outcomes of ACE-designated patients admitted to the ACE unit versus bed-spaced peers cared for using a protocolized ACE order set. METHODS: 3046 ACE-designated patient admissions were analyzed (1499 ACE unit and 1547 bed-spaced). The primary outcomes examined were discharge disposition and in-hospital mortality. Univariate and multivariate comparisons were performed. Propensity matching was used to adjust for case mix in a post-hoc analysis. RESULTS: The mean age of participants was 83.5 years for ACE unit patients and 82.6 for bedspaced patients. In adjusted models, ACE unit patients were more likely to be discharged home (OR 1.28 [1.08-1.50], p = 0.003). In an unadjusted analysis, patients admitted to ACE unit were less likely to die in hospital, but this finding did not persist after adjustment for case mix. CONCLUSION: Care of older adults delivered on a dedicated ACE unit increases the likelihood of discharge to home when compared to care delivered with an ACE order set alone for general internal medicine patients.

Effect of a Multimodal Educational Intervention on Use of Urinary Catheters in Hospitalized Individuals.

BACKGROUND/OBJECTIVES: Urinary catheters are frequently used in hospital inpatients despite their association with greater morbidity and mortality. Reducing their unnecessary use can improve patient care. The objective of the current study was to determine the effectiveness of a multimodal nursing and physician education intervention to reduce the unnecessary use of urinary catheters in adult inpatients. DESIGN: Quasi-experimental interrupted time series study. SETTING: General internal medicine and surgical services of a large urban teaching hospital. PARTICIPANTS: Admissions to the services under study during the study period (September 2009 to February 2013) (N = 21,550). INTERVENTION: A multimodal educational intervention incorporating educational posters, small-group teaching sessions, and changes to the hospital's electronic health records and nursing clinical documentation systems were introduced to nurses and physicians. MEASUREMENTS: Mean catheter days per patient (CDPP) and incidence of urinary catheterization, measured at monthly intervals throughout the study period. RESULTS: A decrease in mean CDPP of 5.6 and 6.5 days (P < .001) respectively was observed on the medical and surgical services following the intervention. The monthly incidence of catheterization decreased by 3.0 percentage points on medical units and 6.4 percentage points on surgical units immediately after the intervention, from an average of 14.5% and 15.0%, respectively, before the intervention. Similar degrees of improvement were observed for individuals of all ages, although older adults remained more likely to be catheterized. The effect persisted over nearly 3 years of observed follow-up. CONCLUSIONS: A relatively simple multimodal educational intervention targeting nurses and physicians resulted in a significant and sustained reduction in CDPP and the proportion of participants catheterized.

Finite element modeling of the human sclera: influence on optic nerve head biomechanics and connections with glaucoma.

Scleral thickness, especially near the optic nerve head (ONH), is a potential factor of interest in the development of glaucomatous optic neuropathy. Large differences in the dimensions of the sclera, the principal load-bearing tissue of the eye, have been observed between individuals. This study aimed to characterize the effects of these differences on ONH biomechanics. Eleven enucleated human globes (7 normal and 4 ostensibly glaucomatous) were imaged using high-field microMRI and segmented to produce 3-D individual-specific corneoscleral shells. An identical, idealized ONH geometry was inserted into each shell. Finite element modeling predicted the effects of pressurizing the eyes to an IOP of 30 mmHg, with the results used to characterize the effect of inter-individual differences in scleral dimensions on the biomechanics of the ONH. Measurements of the individual-specific corneoscleral shells were used to construct a 2-D axisymmetric idealized model of the corneoscleral shell and ONH. A sensitivity analysis based on this model quantified the relative importance of different geometrical characteristics of the scleral shell on the biomechanics of the ONH. Significant variations were observed in various measures of strain in the idealized lamina cribrosa (LC) across the seven normal corneoscleral shells, implying large differences in individual biomechanics due to scleral anatomy variations alone. The sensitivity analysis revealed that scleral thickness adjacent to the ONH was responsible for the vast majority of variation. Remarkably, varying peripapilary scleral thickness over the physiologically measured range changed the peak (95th percentile) first principal strain in the LC and radial displacement of the ONH canal by an amount that was equivalent to a change in IOP of 15 mmHg. Inter-individual variations in scleral thickness, particularly peripapillary scleral thickness, can result in vastly different biomechanical responses to IOP. These differences may be significant for understanding the interactions between IOP and scleral biomechanics in the pathogenesis of glaucomatous optic neuropathy. The relationship between scleral thickness and material properties needs to be studied in human eyes.

2-Phenyl-2-(pyridin-2-yl)hexahydro-pyrimidine.

The title compound, C(15)H(17)N(3), was prepared by reaction of benzoyl-pyridine and hexahydropyrimidine. The 1,3-diazinane ring adopts a chair conformation with one N-H group axial and the other equatorial. The axial N-H group participates in very weak hydrogen bonding to the lone pair of electrons of the N atom with the equatorial H atom producing a very weakly hydrogen-bonded dimer. The pyridine N atom accepts an inter-nal hydrogen bond from the equatorial H atom. The phenyl ring adopts an equatorial position while the pyridine ring is axial. The phenyl ring exhibits a slight twist (ca 25°) relative to the hexahydropyrimidine ring. The pyridine ring stacks with symmetry-related pyridine rings.

Dimensions of the human sclera: Thickness measurement and regional changes with axial length.

Scleral thickness, especially near the region of the optic nerve head (ONH), is a potential factor of interest in the development of glaucomatous optic neuropathy. Our goal was to characterize the scleral thickness distribution and other geometric features of human eyes. Eleven enucleated human globes (7 normal and 4 ostensibly glaucomatous) were imaged using high-field microMRI, providing 80 microm isotropic resolution over the whole eye. The MRI scans were segmented to produce 3-D corneoscleral shells. Each shell was divided into 15 slices along the anterior-posterior axis of the eye, and each slice was further subdivided into the anatomical quadrants. Average thickness was measured in each region, producing 60 thickness measurements per eye. Hierarchical clustering was used to identify trends in the thickness distribution, and scleral geometric features were correlated with globe axial length. Thickness over the whole sclera was 670 +/- 80 microm (mean +/- SD; range: 564 microm-832 microm) over the 11 eyes. Maximum thickness occurred at the posterior pole of the eye, with mean thickness of 996 +/- 181 microm. Thickness decreased to a minimum at the equator, where a mean thickness of 491 +/- 91 microm was measured. Eyes with a reported history of glaucoma were found to have longer axial length, smaller ONH canal dimensions and thinner posterior sclera. Several geometrical parameters of the eye, including posterior scleral thickness, axial length, and ONH canal diameter, appear linked. Significant intra-individual and inter-individual variation in scleral thickness was evident. This may be indicative of inter-individual differences in ocular biomechanics.

Bis(thio-cyanato-κN)[tris-(2-pyridylmeth-yl)amine-κN,N',N'',N''']nickel(II) methanol hemisolvate.

The title complex, [Ni(NCS)(2)(C(18)H(18)N(4))]·0.5CH(3)OH, consists of two crystallographically distinct complexes and a methanol solvent mol-ecule. The Ni(II) complexes are pseudo-octa-hedral six-coordinate, with the tris-(2-pyridylmeth-yl)amine (TPA) ligand providing four N atoms and two N-bound thio-cyanates providing the final two N atoms. The distances and angles are typical for Ni(II)-TPA complexes. The compound has unit-cell parameters that are surprisingly similar to the previously reported hydrate.

Understanding the mechanism of H(+)-induced demetalation as a design strategy for robust iron(III) peroxide-activating catalysts.

The FeIII-TAML (tetra-amido macrocyclic ligand) activators 1 (Y = Cl) and 2 (Y = H2O), a (R = Me, X = H), b (Me, Cl), c (Me, MeO), d (Et, Cl), e (F, H), f (F, Cl), are five-coordinated in the solid state (X-ray crystallography) but are six-coordinated species in water with two H2O axial ligands. The first pKa's of aqueous ligands are in the range of 9.5-10.5. The acid-induced demetalation of 2 follows the equation kobs = k1*[H+] + k3*[H+]3. The rate constants k1* and k3* vary by 5 and 11 orders of magnitude depending on the nature of substituents R. The highest stabilization against the demetalation is achieved for R = F.

Tribromo(3,5-dimethyl-2-nitrophenyl-kappa(2)C(1),O)tellurium(IV), bromo(3,5-dimethyl-2-nitrophenyl-kappa(2)C(1),O)tellurium(II) and bromo(3,5-dimethyl-2-nitrosophenyl-kappa(2)C(1),O)tellurium(II).

All three title compounds, prepared from bis(3,5-dimethyl-2-nitrophenyl)ditellurium, exhibit high degrees of intramolecular Te-O coordination. Their Te-O distances increase in the order C(8)H(8)BrNOTe < C(8)H(8)BrNO(2)Te < C(8)H(8)Br(3)NO(2)Te, with distances of 2.165 (3), 2.306 (1) and 2.423 (6) A, respectively, indicating that C(8)H(8)BrNOTe may be more aptly described as 1-bromo-4,6-dimethyl-2,1,3-benzoxatellurazole.