Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 220
Filtrar
2.
J Adv Nurs ; 2020 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-32420652

RESUMO

The 21st century has seen several infectious disease outbreaks that have turned into epidemics and pandemics including Severe Acute Respiratory Syndrome (SARS) which began in Asia in 2003 (Poon, Guan, Nicholls, Yuen, & Peiris, 2004), followed by H1N1 that emerged in Mexico and the United States in 2009 (Belongia et al., 2010). Next came the lesser known Middle East Respiratory Syndrome (MERS) originating in Saudi Arabia in 2012 (Assiri et al., 2013), after which the Ebola outbreak in West Africa took place from 2014 to 2016, with a more recent occurrence in the Democratic Republic of Congo from 2018 to 2019 (Malvy, McElroy, de Clerck, Günther, & van Griensven, 2019). To date, the coronavirus (COVID-19) outbreak that started in Wuhan, in the Hubei province of China, in late December 2019 seems to be eclipsing all of these previous infectious diseases in terms of its global reach and impact (Wang, Horby, Hayden, & Gao, 2020). After being declared by the World Health Organization (WHO) as a public health emergency on 30 January 2020 (World Health Organization, 2020c), it was elevated to a pandemic status on 11 March 2020 (World Health Organization, 2020d). As of 28 April 2020, there are more than 2.9 million cases and 202,597 deaths reported worldwide (World Health Organization, 2020b).

3.
Nano Lett ; 2020 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-32315534

RESUMO

Manipulation of plasmon modes at ultraviolet wavelengths using engineered nanophotonic devices allows for the development of high-sensitivity chiroptical spectroscopy systems. We present here an experimental framework based on aluminum-based crescent-shaped nanostructures that exhibit a strong chiroptical response at ultraviolet wavelengths. Through utilization of higher-order plasmon modes in wavelength-scale nanostructures, we address the inherent fabrication challenges in scaling the response to higher frequencies. Additionally, the distinct far-field spectral response types are analyzed within a coupled-oscillator model framework. We find two competing chiroptical response types that contribute toward potential ambiguity in the interpretation of the circular dichroism spectra. The first, optical activity, originates from the interaction between hybridized eigenmodes, whereas the second manifests as a response superficially similar to optical activity but originating instead from differential near-field absorption modes. The study of the chiroptical response from nanoplasmonic devices presented here is expected to aid the development of next-generation chiroptical spectroscopy systems.

4.
Artigo em Inglês | MEDLINE | ID: mdl-32303779

RESUMO

RATIONALE: Effort-related choice tasks are used to study aspects of motivation in both rodents and humans (Der-Avakian and Pizzagalli Biol Psychiatry 83(11):932-939, 2018). Various dopaminergic manipulations and antidepressant treatments can shift responding to these tasks (Randall et al. Int J Neuropsychopharmacol 18(2), 2014; Yohn et al. Psychopharmacology 232(7):1313-1323, 2015). However, while chronic stress can precipitate mood disorders in humans, there is relatively little known about whether chronic stress elicits maladaptive behaviors in rodent effort-related choice tasks. OBJECTIVES: Chronic corticosterone (CORT) elicits an increase in negative maladaptive behaviors in male mice (David et al. Neuron 62(4):479-493, 2009; Gourley et al. Biol Psychiatry 64(10):884-890, 2008; Olausson et al. Psychopharmacology 225(3):569-577, 2013). We hypothesized that chronic CORT administration to male mice would reduce motivation for a higher effort, higher reward option, and shift responding to a less effortful, but a lesser reward. METHODS: Adult male C57BL/6J mice were administered either vehicle (n = 10) or CORT (n = 10) (~ 9.5 mg/kg/day) in their drinking water for 4 weeks, and then throughout all behavioral experiments (15 weeks total), and were tested in a Y-Maze barrier task and a fixed ratio concurrent (FR/chow) choice task. RESULTS: Chronic CORT reduced Y-maze HR arm choice when more effort was required to obtain the 4 food pellets (15-cm barrier in the high-reward (HR) arm, p < 0.001; 20-cm barrier in HR arm, p < 0.001) and shifted choice to the low reward (LR) arm where only 2 pellets were available. Chronic CORT also reduced lever pressing for food pellets in FR30/chow sessions of the concurrent choice task (p = 0.009), without impacting lab chow consumed. CONCLUSIONS: Chronic stress induces maladaptive shifts in effort-related choice behavior in the Y-maze barrier task in male mice. Furthermore, males subjected to chronic CORT administration show reduced lever pressing in FR30/chow sessions where lab chow is concurrently available. These data demonstrate that chronic corticosterone reduces motivation to work for and obtain a highly rewarding reinforcer when a lesser reinforcer is concurrently available.

5.
ISA Trans ; 2020 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-32171595

RESUMO

This paper proposes a novel similarity-based algorithm for Remaining Useful Life (RUL) prediction and a methodology for machine prognostics. In the proposed RUL prediction algorithm, a Similarity Matching Procedure including the Kernel Two Sample Test (KTST) is developed to query similar run-to-failure (R2F) profiles from historical data library. Next, the preliminary predictions of RUL are obtained as remaining time-to-failure from the similar R2F records. In the last step, Weibull analysis is performed to fuse the preliminary predictions and to obtain the probability distribution of RUL. Moreover, a methodology for machine prognostics is developed based on the RUL prediction algorithm. Compared with existing similarity-based methods for RUL prediction, the proposed method holds several advantages: 1) the similarities between sensor readings or feature matrices are directly measured without extra health assessment procedure; 2) the proposed method presents good probabilistic interpretations of the prediction uncertainties; 3) the estimated RUL distribution is statistically sound by applying KTST to prescreening the historical R2F records. The effectiveness and the superiority of the proposed method are justified based on the public aero-engine dataset.

6.
Transplantation ; 2020 Feb 04.
Artigo em Inglês | MEDLINE | ID: mdl-32022738

RESUMO

OBJECTIVE: To define prevalence and changes in opioid use before and after liver transplant. BACKGROUND: Opioid use in liver transplantation is poorly understood and has potential associated morbidity. METHODS: Using a national dataset of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between 12/2009-2/2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid-naïve/no fills, chronic opioid use (≥120 day supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peritransplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use posttransplant. RESULTS: Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Posttransplant, 61% of patients filled an opioid prescription 0-2 months after discharge, and 21% filled an opioid between 10-12 months after discharge. Among previously opioid-naïve patients, 4% developed chronic use posttransplant. Among patients with pretransplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pretransplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased posttransplant opioid use. CONCLUSION: Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use posttransplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

8.
Ann Surg ; 271(1): 86-93, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31478976

RESUMO

OBJECTIVE: Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. SUMMARY BACKGROUND DATA: During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. METHODS: We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. RESULTS: Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. CONCLUSION: A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.

9.
Health Soc Care Community ; 28(2): 591-601, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31750578

RESUMO

Ethnic minorities across the globe encounter disparities in healthcare. While a great deal of research has been conducted on the experiences of these patients, studies focusing on the perspectives of healthcare professionals are limited, particularly in the context of Asia. This study explores the perceptions of and challenges faced by Hong Kong healthcare professionals in the provision of culturally appropriate care to South Asian ethnic minority patients. Taking a qualitative approach, interviews were conducted with 22 healthcare professionals. Two main themes were identified: 'lack of support' at the healthcare system level and 'dysfunctional relationship with South Asian ethnic minority patients' at the interpersonal level. Challenges at the healthcare system level include information outreach, cultural competency, utilisation of available resources and time and workload, whereas challenges at the interpersonal level include patient-provider interaction, patient-provider perceptions of illness and care and patient-provider sociocultural discordance. Intercultural care was found to be influenced by both the healthcare system and interpersonal characteristics. The study highlights the need for healthcare professional education and training in cultural competency, in order to improve the provision of intercultural care. Identifying the challenges faced by healthcare professionals and the implications of these challenges for the provision of healthcare to South Asian ethnic minority patients will help practitioners, policy makers and care provider agencies to improve quality of care and health outcomes for culturally diverse patients.

10.
Water Res ; 170: 115326, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31838363

RESUMO

Every member of the ecological community is connected via a network of vital and complex relationships, called the web of life. To elucidate the ecological network and interactions among producers, consumers, and decomposers in the Daechung Reservoir, Korea, during cyanobacterial harmful algal blooms (cyanoHAB), especially those involving Microcystis, we investigated the diversity and compositions of the cyanobacterial (16S rRNA gene), including the genotypes of Microcystis (cpcBA-IGS gene), non-cyanobacterial (16S), and eukaryotic (18S) communities through high-throughput sequencing. Microcystis blooms were divided into the Summer Major Bloom and Autumn Minor Bloom with different dominant genotypes of Microcystis. Network analysis demonstrated that the modules involved in the different phases of the Microcystis blooms were categorized into the Pre-Bloom, Bloom, Post-Bloom, and Non-Bloom Groups at all sampling stations. In addition, the non-cyanobacterial components of each Group were classified, while the same Group showed similarity across all stations, suggesting that Microcystis and other microbes were highly interdependent and organized into cyanoHAB-related module units. Importantly, the Microcystis genotype-based sub-network uncovered that Pirellula, Pseudanabaena, and Vampirovibrionales preferred to interact with specific Microcystis genotypes in the Summer Major Bloom than with other genotypes in the Autumn Minor Bloom, while the copepod Skistodiaptomus exhibited the opposite pattern. In conclusion, the transition patterns of cyanoHAB-related modules and their key components could be crucial in the succession of Microcystis genotypes and to enhance the understanding of microbial ecology in an aquatic environment.


Assuntos
Cianobactérias , Microcystis , Genótipo , RNA Ribossômico 16S , República da Coreia
11.
Ann Surg ; 271(2): 290-295, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30048311

RESUMO

OBJECTIVE: To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed. SUMMARY OF BACKGROUND DATA: Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited. METHODS: A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outcome was a change in opioid prescription share for opioid-naive patients undergoing surgical, emergency, and dental care from 2010 to 2016; we also examined the type and amounts of opioid filled. RESULTS: From 87,941,718 analyzed lives, we identified 16,292,018 opioid prescriptions filled by opioid-naive patients. The proportion of prescriptions for patients receiving surgery, emergency, and dental care increased by 15.8% from 2010 to 2016 (P < 0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing. In 2016, surgery patients filled 22.0% of initial prescriptions, emergency medicine patients 13.0%, and dental patients 4.2%. Surgical patients' mean total oral morphine equivalents per prescription increased from 240 mg (SD 509) in 2010 to 403 mg (SD 1369) in 2016 (P < 0.001). Over the study period, surgical patients received the highest proportion of potent opioids (90.2% received hydrocodone or oxycodone). CONCLUSIONS: Initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care. Evidence-based guideline development for surgical and dental prescribing is warranted in order to curb iatrogenic opioid morbidity and mortality.

12.
Heart Rhythm ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31837474

RESUMO

BACKGROUND: Cardiac sympathetic denervation (CSD) is a promising treatment for patients with structural heart disease (SHD) and refractory ventricular tachyarrhythmias (VTs). The effect of CSD on atrial rhythm as well as the prognostic impact of atrial arrhythmias (AAs) or left atrial volume index (LAVI) on CSD outcome are unknown. OBJECTIVES: The goals of this study were to evaluate the impact of AAs and LAVI on CSD outcome and to assess changes in AAs burden and in atrial pacing after CSD. METHODS: Patients with SHD undergoing CSD for VTs were analyzed. Hazards models were built to assess predictors of sustained VT/implantable cardioverter-defibrillator (ICD) shock recurrences and death/orthotopic heart transplant (OHT). Changes before vs after CSD were assessed using ICD, clinical, and echocardiographic data. A drug index was devised to correct for medication use. RESULTS: Between 2009 and 2018, 91 patients (mean age 56 ± 13 years; mean left ventricular ejection fraction 34% ± 14%; 47% with a history of AAs) underwent left CSD (16%) or bilateral CSD (BCSD). The median follow-up was 14 months (interquartile range 4-37 months). Using multivariable analysis, neither LAVI nor AAs were associated with recurrences; LAVI was an independent predictor of death/OHT. AAs burden did not change after BCSD, but atrial pacing increased from a median of 28% to 72% (P < .01). Left ventricular end-diastolic diameter slightly increased; however, sustained VT/ICD shocks were reduced. CONCLUSION: In patients with SHD undergoing CSD, LAVI predicts death/OHT. AAs burden, already low at baseline, was unchanged after BCSD, while the need for atrial pacing increased, suggesting an impact of BCSD on sinus node chronotropism.

13.
JAMA Netw Open ; 2(12): e1918361, 2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31880801

RESUMO

Importance: Since the Centers for Disease Control and Prevention published opioid prescribing guidelines in March 2016, 31 states have implemented legislation to restrict the duration of opioid prescriptions for acute pain. However, the association of these policies with the amount of opioid prescribed following surgery remains unknown. Objective: To examine the association of opioid prescribing duration limits with postoperative opioid prescribing in Massachusetts and Connecticut, the first 2 states to implement limits after March 2016. Design, Setting, and Participants: This interrupted time series analysis and cross-sectional study examined immediate level and slope changes in monthly outcomes after prescribing limit implementation in Massachusetts and Connecticut. These states implemented 7-day limits on initial opioid prescriptions on March 14, 2016, and July 1, 2016, respectively. Using the 2014 to 2017 IBM MarketScan Research Database, 16 281 opioid-naive adults in these states who filled a prescription within 3 days of surgery between July 1, 2014, and November 30, 2017, were identified. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures: The primary outcome was the prescription size in oral morphine equivalents (OMEs) for the initial postoperative opioid prescription (one 5/325 mg hydrocodone-acetaminophen pill = 5 OMEs). Secondary outcomes included days supplied in the initial prescription and the proportion of initial prescriptions exceeding a 7-day supply. Results: In total, 16 281 opioid-naive patients (9708 [59.6%] female; median [interquartile range] age range, 45-54 [35-44 to 55-64] years) undergoing surgical procedures were included. In Massachusetts, there were 5340 and 5435 patients in the preimplementation and postimplementation periods, respectively. In Connecticut, there were 2869 and 2637 patients in the preimplementation and postimplementation periods, respectively. Limit implementation in Massachusetts was associated with an immediate mean level decrease in prescription size (-38 OMEs [95% CI, -44 to -32 OMEs]) and with a mean decrease in slope (-1.5 OMEs/mo [95% CI, -2.1 to -0.9 OMEs/mo]). Implementation was also associated with an immediate mean level decrease in days supplied (-0.4 days [95% CI, -0.6 to -0.2 days]) and the proportion of prescriptions exceeding a 7-day supply (-5.9 percentage points [95% CI, -7.9 to -3.9 percentage points]). In contrast, limit implementation in Connecticut was not associated with level or slope changes in any outcome. Conclusions and Relevance: Opioid prescribing duration limits had a variable association with postoperative opioid prescribing in Massachusetts and Connecticut. The mean opioid prescription size filled, days supplied, and prescribing exceeding a 7-day supply decreased after limit implementation in Massachusetts only. Given the potential differences in policy dissemination and uptake, efforts to reduce opioid prescribing should also include surgeon education and evidence-based prescribing recommendations.

14.
Ann Surg ; 2019 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-31851641

RESUMO

MINI: In this analysis of insurance claims, we observed that new persistent opioid use was independently associated with significantly higher total health care spending during the 180 days after surgery, primarily due to higher utilization of ambulatory care and readmissions. Targeted value-based care initiatives may be required to incentivize early identification and coordinated pathways of care for patients with new persistent opioid use after surgery. OBJECTIVE: We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use. SUMMARY OF BACKGROUND DATA: Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown. METHODS: We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates. RESULTS: In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month. CONCLUSION: Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.

15.
Ann Transl Med ; 7(Suppl 6): S235, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31656814
16.
Sci Adv ; 5(10): eaav8262, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31646174

RESUMO

The potential for enhancing the optical activity of natural chiral media using engineered nanophotonic components has been central in the quest toward developing next-generation circular-dichroism spectroscopic techniques. Through confinement and manipulation of optical fields at the nanoscale, ultrathin optical elements have enabled a path toward achieving order-of-magnitude enhancements in the chiroptical response. Here, we develop a model framework to describe the underlying physics governing the origin of the chiroptical response in optical media. The model identifies optical activity to originate from electromagnetic coupling to the hybridized eigenstates of a coupled electron-oscillator system, whereas differential absorption of opposite handedness light, though resulting in a far-field chiroptical response, is shown to have incorrectly been identified as optical activity. We validate the model predictions using experimental measurements and show them to also be consistent with observations in the literature. The work provides a generalized framework for the design and study of chiroptical systems.

17.
Biotechnol Biofuels ; 12: 242, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31632454

RESUMO

Background: Current efforts on the optimization of the two-stage cultivation using stress-induced lipid accumulation have mostly focused only on the lipid induction stage. Although recent studies have shown that stress-induced lipid accumulation is affected by the physiological status of the cells harvested at the preceding cultivation stage, this issue has hardly been examined hitherto. Such a study needs to be carried out in a systematic way in order to induce lipid accumulation in a consistent and predictable manner with regard for variances seen at the cultivation stage. Results: After a photoautotrophic cultivation of Chlorella sorokiniana HS1 in a modified BG11, harvested cells were re-suspended in the fresh medium, and then NaCl was added as the sole stress inducer with light illumination to induce additional accumulation of lipid. Effects of culture temperature on the lipid accumulation were analyzed by the Kruskal-Wallis test. From the microscopic observation, we had observed a definite increase in lipid body induced by the stress since the cell entered a stationary phase. A multiple linear regression model was developed so as to identify significant parameters to be included for the estimation of lipid induction. As a result, several key parameters at the end of cultivation, such as cell weight, total lipid content, chlorophyll a in a cell, and Fv/Fm, were identified as the important proxy variables for the cell's physiological status, and the modeling accuracy was achieved by 87.6%. In particular, the variables related to Fv/Fm were shown to have the largest influence, accounting for 65.7% of the total variance, and the Fv/Fm had an optimal point of maximum induction at below its average. Clustering analysis using the K-means algorithm indicated that the algae which are 0.15 pg cell-1 or less in chlorophyll concentration, regardless of other conditions, had achieved high induction results. Conclusion: Experimental results showed that it usually achieves high lipid induction after the cells naturally end their division and begin to synthesize lipid. The amount of lipid induction could be estimated by the selected proxy variables, and the estimation method can be adapted according to practical situations such as those with limited measurements.

18.
Can Urol Assoc J ; 13(10): 301-306, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31364978

RESUMO

INTRODUCTION: Natesto®, testosterone nasal gel (TNG), is a testosterone therapy (TTh) indicated for adult male hypogonadism. This study allowed titration decisions to be based on physicians' assessment of patient symptoms. METHODS: Hypogonadal males on active topical testosterone therapy (TThE) or naive to any form of testosterone therapy (TThN) were treated with 22 mg TNG daily (11 mg twice daily) for 90 days. Titration was determined by the physician at day 90 wherein the dose was increased to 33 mg daily if symptoms were not properly managed. Total testosterone (TT) levels were collected at day 90 and 120 and the quantitative Androgen Deficiency in the Aging Male (qADAM) symptom questionnaire was administered on days 0, 30, 60, 90, and 120. RESULTS: At study endpoint, 77.0% of all patients were in the normal TT range. Mean qADAM scores increased from 30.8 at baseline to 35.5 (6.6) at day 90. Physician assessments resulted in 37% patients being up-titrated for an additional 30 days, however, qADAM scores did not change significantly at the higher dose. CONCLUSIONS: The majority of patients achieved the normal range of testosterone with TNG when physicians based their titration decision on an assessment of symptoms. Sexual function and energy-related symptoms were predictive of improvements resulting from treatment. These symptoms were the most relevant indicators for physicians in making decisions relating to titration.

19.
Surgery ; 166(5): 744-751, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31303324

RESUMO

BACKGROUND: Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets. METHODS: We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors. RESULTS: Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration). CONCLUSION: This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.


Assuntos
Analgésicos Opioides/uso terapêutico , Atitude do Pessoal de Saúde , Dor Pós-Operatória/tratamento farmacológico , Transferência de Pacientes/organização & administração , Papel Profissional , Adulto , Prescrições de Medicamentos , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Médicos de Atenção Primária/organização & administração , Médicos de Atenção Primária/psicologia , Padrões de Prática Médica/organização & administração , Pesquisa Qualitativa , Cirurgiões/organização & administração , Cirurgiões/psicologia
20.
J Am Coll Surg ; 229(3): 316-322, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31154092

RESUMO

BACKGROUND: Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. STUDY DESIGN: Patients undergoing 6 procedures were offered the opportunity to participate in an opioid-sparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small "rescue" opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. RESULTS: A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 ± 14 vs 59 ± 13 years; p = 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p = 0.014), received larger rescue prescriptions (6 ± 3 vs 4 ± 4 pills; p = 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p = 0.001). There were no other significant differences between opioid users and non-users. CONCLUSIONS: Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA