Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study.

BACKGROUND: Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers. OBJECTIVES: To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system. DESIGN: Qualitative research. PARTICIPANTS: We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs). APPROACH: We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus. RESULTS: Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines. CONCLUSIONS: Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy.

OBJECTIVES: Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. METHODS: Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). RESULTS: Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/µL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/µL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/µL (mean rise per year: 52 cells/µL for no opioids vs. 20 cells/µL for short-term opioids; P = 0.04); findings were otherwise unchanged. CONCLUSIONS: Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.

All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors.

BACKGROUND: While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality. METHODS: Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD). RESULTS: There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively). CONCLUSIONS: Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.

Ovine interferon-tau inhibits estrogen receptor up-regulation and estrogen-induced luteolysis in cyclic ewes.

This study determined whether intrauterine injection of interferon-tau (IFN tau) could block luteolysis in cyclic ewes treated with a luteolytic dose of 17 beta-estradiol benzoate (E) on day 12 of the estrous cycle. Thirty-two ewes were fitted with uterine catheters on day 5 of the estrous cycle and treated with recombinant ovine IFN tau (2 x 10(7) antiviral units/ewe/day) or control proteins (6 mg/day) by intrauterine injection from day 10 until hysterectomy. At 1900 h on day 12, all ewes received 750 micrograms E, im, and were hysterectomized 12, 24, 36, or 48 h post-E administration. Plasma concentrations of progesterone declined in control animals but increased in IFN tau-treated ewes after E injection (P < 0.01, treatment x day interaction). Likewise, total corpus luteum weight decreased in control but not IFN tau-treated ewes after E administration (P < 0.02, treatment x time interaction). In control ewes, endometrial estrogen receptor (ER) messenger RNA (mRNA; P < 0.03) and progesterone receptor (PR) mRNA (P < 0.10) increased after 12 h, whereas concentrations of ER protein (P < 0.02) and PR protein (P < 0.04) increased after 24 h. In situ hybridization and immunohistochemical analyses indicated that ER gene expression increased first in the epithelium at 12 h and then in the stroma by 48 h, whereas PR gene expression first increased in the stroma and then in the epithelium. In control ewes, endometrial oxytocin receptor (OTR) density increased (P < 0.10) after 12 h, with the largest increase occurring between 36-48 h. In IFN tau-treated ewes, endometrial ER mRNA and protein and OTR density did not increase after E administration. Levels of PR mRNA increased (P < 0.01) between 12-36 h, but decreased after 36 h. PR mRNA abundance increased between 12-36 h in the stroma, but not in the epithelium. Concentrations of PR protein were low and did not change in IFN tau-treated ewes. Immunoreactive PR protein was present at low levels in the stroma of all IFN tau-treated ewes. The results indicate that induction of luteolysis by E in control ewes involved sequential increases in endometrial ER mRNA and ER protein in the epithelium that preceded maximal increases in OTR density. Intrauterine injection of recombinant ovine IFN tau prevented luteolysis by inhibiting estrogen-induced increases in endometrial ER and OTR gene expression.

Intrauterine injection of ovine interferon-tau alters oestrogen receptor and oxytocin receptor expression in the endometrium of cyclic ewes.

This study determined the effects of intrauterine injections of recombinant ovine interferon-tau; (roIFN-tau; 2 x 10(7) antiviral units/day) or control proteins (6 mg/day) from day 11 to day 14 post-oestrus = day 0) on endometrial expression of receptors fro oestrogen, progesterone and oxytocin in cyclic ewes. Plasma concentrations of progesterone were greater on day 15 in ewes receiving roIFN-tau compared with control proteins (P < 0.02, treatment x day). Ewes injected with roIFN-tau had lower endometrial levels or oestrogen receptor mRNA (P > 0.10) and protein (P < 0.01) on day 15 compared with ewes receiving control proteins. In situ hybridization analysis indicated that oestrogen receptor mRNA was more abundant in the luminal and glandular epithelium of control ewes compared with roIFN-tau-treated ewes. Immunoreactive oestrogen receptor was also present in the luminal and glandular epithelium of control, but not roIFN-tau-treated ewes. Endometrial levels of progesterone receptor mRNA and protein were not different (P > 0.10) between control and roIFN-tau-treated ewes. In situ hybridization analyses indicated that progesterone receptor mRNA abundance was low in endometrial epithelium and stroma of both control and roIFN-tau-injected ewes. Immunoreactive progesterone receptors were present in the endometrial stroma and epithelium of control ewes, but confined to the stroma of roIFN-tau-treated ewes. Oxytocin receptor density was lower (P < 0.01) in the endometrium of ewes injected with roIFN-tau than control proteins; however, oxytocin receptor affinity was not affected (P > 0.10) by treatment. Concentrations of 13,14-dihydro-15-ketoprostaglandin F2a (PGFM) were not increased by exogenous oxytocin administration in control and roIFN-tau-treated ewes on days 10 or 12 post-oestrus. However, on day 14, control ewes responded to oxytocin with increased plasma concentrations of PGFM, whereas ewes receiving roIFN-tau remained unresponsive to oxytocin. These results indicate that the an tiluteolytic effects of IFN-tau are to prevent increases in endometrial oestrogen receptor MRNA and protein and oxytocin receptor density which abrogates uterine release of prostaglandin F2a during maternal recognition of pregnancy. IFN-tau may inhibit the synthesis of oestrogen receptor mRNA by a transcriptional or post-transcriptional regulatory mechanism to suppress oxytocin receptor formation during early pregnancy in ewes.

Relationship between phosphoinositide hydrolysis and prostaglandin F2 alpha secretion in vitro from endometrium of cyclic pigs on day 15 postestrus.

The mechanism for the luteolytic release of prostaglandin (PG)F2 alpha in swine is not known. This study examined the potential role of oxytocin (OT)-induced phosphoinositide (PI) hydrolysis in promoting PGF2 alpha secretion in vitro from the endometrium of cyclic gilts on Day 15 postestrus. In Experiment 1, endometrial PI hydrolysis was increased (P < 0.05) by 100 nM OT and was increased quadratically (P < 0.05) by LiCl, but was not affected by the LiCl x OT interaction (P > 0.30). PI hydrolysis was maximal at 50 mM LiCl and declined at 100 mM LiCl. In Experiment 2, endometrial PI hydrolysis and PGF2 alpha secretion were similarly increased (P < 0.01) by 0, 0.1, 1, 10, and 100 nM OT in a dose-dependent manner. In Experiment 3, the linear increase in PI hydrolysis occurring 0, 3, 5, 10, and 20 min after treatment was greater (P = 0.01) for tissue treated with 100 nM OT than for the tissue treated with 0 nM OT. The quadratic increase (P < 0.05) in PGF2 alpha secretion occurring 0, 3, 5, 10, and 20 min after treatment was greater (P < 0.05) for tissue treated with 100 nM OT than for the tissue treated with 0 nM OT. In Experiment 4, AlF4- (an activator of Gp and phospholipase C) similarly increased (P < 0.01) PI hydrolysis and PGF2 alpha secretion. In Experiment 5, PI hydrolysis (P < 0.01) and PGF2 alpha secretion (P < 0.05) were increased by 100 nM OT but were not stimulated by cholera toxin (an activator of Gs and adenylate cyclase). Cholera toxin also did not enhance PI hydrolysis and PGF2 alpha secretion in response to 0.1 or 100 nM OT. These results are consistent with the hypothesis that OT may induce PI hydrolysis to stimulate the endometrial secretion of PGF2 alpha during corpus luteum regression in swine.

Effect of group thawing on post-thaw viability of bovine spermatozoa packaged in .5-milliliter French straws.

The objective of this study was to determine the effects of thawing groups of 2, 5, 10, 15, or 20 .5-ml French straws on post-thaw spermatozoal viability. Thermostatically controlled and nonthermostatically controlled thawing baths were compared. Using a split-plot design, semen from 10 bulls was extended in egg yolk citrate, frozen, and then thawed (in the respective groups) at 36 degrees C in two types of thawing baths. Motility and percentage of intact acrosomes were determined immediately after thawing (0 h) and again after 4 h of incubation at the respective temperature of each thawing bath. Neither percentage of intact acrosomes nor motility was influenced by the number of straws thawed at 0 h (P greater than .05). Thawing bath had no effect (P greater than .05) on motility or percentage of intact acrosomes at 0 h. Bull variation was significant in both the 0- and 4-h evaluations. After 4 h of incubation, there was a significant (P less than .05) straw number x thawing bath interaction. When 15 or 20 straws were thawed in the thermostatically controlled bath there was a reduction (P less than .05) in motility and percentage of intact acrosomes. However, in the nonthermostatically controlled bath there was no reduction in motility and percentage of intact acrosomes as the size of straw group increased. Our results indicate that, when using a nonthermostatically controlled thawing bath, semen packaged in .5-ml straws can be thawed in groups of 20 without an effect on post-thaw sperm viability.

Influence of cornual insemination on conception in dairy cattle.

The objective of this study was to compare conception to artificial insemination (AI) services in dairy cattle when semen was deposited into the uterine body or into both uterine horns (cornual insemination). Nine herdsman inseminators (HI) in four commercial dairy herds in Washington constituted the experimental units. Herds ranged in size from 393 cows to 964 cows. The duration of the experiment was 12 mo in three herds and 18 mo in the fourth herd. At the beginning of the experiment all inseminators were trained to deposit semen in the body of the uterus. Inseminators were instructed to use this method for 6 mo. Following employment of body deposition, the same inseminators were retrained to deposit one-half of the semen into the right uterine horn and one-half into the left uterine horn. Cornual inseminations were performed for 6 mo. A total of 4,178 services constituted the data set. Milk samples were collected from cows on the day of insemination and later were assayed for progesterone (P4). There was variation (P less than .01) in conception associated with month of insemination and insemination method (P less than .001). The monthly variation was not associated with season of the year. Least squares means for conception when semen was deposited in the uterine body was 44.7%, compared with 64.6% when cornual insemination was employed. The insemination treatment X inseminator interaction was not significant. Results suggest that cornual insemination provides an alternative to deposition of semen in the uterine body.

Exogenous oxytocin decreases interestrous interval of cyclic gilts.

Oxytocin (OT) stimulates pulsatile secretion of uterine PGF2 alpha in ruminants, but the role of OT in regulation of the estrous cycle of pigs is not clear. four experiments were performed to examine the effect of exogenous OT on interestrous interval of intact cyclic and hysterectomized gilts. In Exp. 1, i.v. injections of 20 USP units (equivalent to 20 IU) of OT, once/day via an ear vein on d 10, 12, 14, and 16 after estrus, decreased (P < .01) interestrous interval (19.9 +/- .2 d) compared with vehicle-injected control gilts (20.8 +/- .2 d), without affecting ovulation rate (12.1 vs. 12.0 +/- .7 corpora lutea; OT vs control gilts) at subsequent estrus. In Exp. 2, i.v. infusions of 20 USP units of OT, twice/day via an indwelling jugular catheter on d 10 to 16 after estrus, did not alter interestrous interval (20.6 +/- .3 d) compared with control gilts (20.4 +/- .3 d). Concentrations of progesterone in jugular vein plasma did not differ between treatment groups on d 9 to 21 after estrus. In Exp. 3, i.m. injections of 20 USP units of OT, twice/day on d 10 to 16 after estrus, decreased (P < .05) interestrous interval (20.6 +/- .4 d) compared with control gilts (22.3 +/- .4 d). In Exp. 4, i.m. injections of 20 USP units of OT, twice/day on d 10 to 16 after estrus, decreased (P < .05) interestrous interval (20.7 +/- .3 d) compared with control injections in uterine-intact gilts (21.8 +/- .3 d). None of the gilts hysterectomized on d 7 and treated on d 10 to 16 after estrus with either OT or control injections returned to estrus by d 28, and all had increased plasma progesterone on d 21 to 27. Mean weight of individual corpora lutea (502 vs 449 +/- 28 mg; OT vs control gilts) and total weight of corpora lutea (5,758 vs. 5,126 +/- 298 mg; OT vs control gilts) of hysterectomized gilts did not differ between treatment groups at ovariectomy on d 28. These results indicate that 1) exogenous OT administered on d 10 to 16 shortened the interestrous interval of intact cyclic gilts and 2) the effect of OT was uterine-dependent.

Production and elimination of disruptive classroom behavior by systematically varying teacher's behavior.

The effects of teacher behaviors on the classroom behaviors of children were investigated by systematically varying approving (praise, smiles, contacts, etc.) and disapproving (verbal reprimands, physical restraint, etc.) classes of teacher behavior. Measures were taken on both teacher and child behaviors. Each day a sample of 10 children was observed. The subject pool was a class of 28 well-behaved children in a middle-primary public school class. The results demonstrated that approving teacher responses served a positive reinforcing function in maintaining appropriate classroom behaviors. Disruptive behaviors increased each time approving teacher behavior was withdrawn. When the teacher's disapproving behaviors were tripled, increases appeared most markedly in the gross motor and noise-making categories of disruptive behavior. The findings emphasize again the important role of the teacher in producing, maintaining, and eliminating disruptive as well as pro-social classroom behavior.

Rules, praise, and ignoring: elements of elementary classroom control.

An attempt was made to vary systematically the behavior of two elementary school teachers to determine the effects on classroom behavior of Rules, Ignoring Inappropriate Behaviors, and showing Approval for Appropriate Behavior. Behaviors of two children in one class and one child in the other class were recorded by observers, as were samples of the teachers' behavior. Following baseline recordings, Rules, Ignoring, and Approval conditions were introduced one at a time. In one class a reversal of conditions was carried out. The main conclusions were that: (a) Rules alone exerted little effect on classroom behavior, (b) Ignoring Inappropriate Behavior and showing Approval for Appropriate Behavior (in combination) were very effective in achieving better classroom behavior, and (c) showing Approval for Appropriate Behaviors is probably the key to effective classroom management.

A token reinforcement program in a public school: a replication and systematic analysis.

A base rate of disruptive behavior was obtained for seven children in a second-grade class of 21 children. Rules, Educational Structure, and Praising Appropriate Behavior while Ignoring Disruptive Behavior were introduced successively; none of these procedures consistently reduced disruptive behavior. However, a combination of Rules, Educational Structure, and Praise and Ignoring nearly eliminated disruptive behavior of one child. When the Token Reinforcement Program was introduced, the frequency of disruptive behavior declined in five of the six remaining children. Withdrawal of the Token Reinforcement Program increased disruptive behavior in these five children, and reinstatement of the Token Reinforcement Program reduced disruptive behavior in four of these five. Follow-up data indicated that the teacher was able to transfer control from the token and back-up reinforcers to the reinforcers existing within the educational setting, such as stars and occasional pieces of candy. Improvements in academic achievement during the year may have been related to the Token Program, and attendance records appeared to be enhanced during the Token phases. The Token Program was utilized only in the afternoon, and the data did not indicate any generalization of appropriate behavior from the afternoon to the morning.

In-vivo and in-vitro effects of ethanol on mouse preimplantation embryos.

In Exp. 1A, hybrid mice (N = 10) were provided with food and 25% (v/v) ethanol as the only source of liquid for 72 h, beginning at the detection of the copulatory plug (08:00 h, Day 1). Control mice received food and tap water. Food consumption (P less than 0.001) but not total caloric intake (P greater than 0.05) was less for the alcohol-treated mice than the controls. Ethanol-derived calories averaged 35% of caloric intake during the 72 h of treatment. Alcohol-treated animals showed a dramatic weight loss until Day 5 while controls gained weight (P less than 0.05). Ethanol consumption did not influence pregnancy rate, litter size or litter weight. In Exp. 1B, animals were treated as in Exp. 1A, but were killed at various times between 24:00 h, Day 1, and 08:00 h, Day 4. Trunk blood was used to determine haematocrit and serum to determine alcohol concentration. Haematocrit was greater (P less than 0.05) for all alcohol-treated mice than for controls at all time periods sampled except one. Dehydration was therefore probably responsible for the weight loss seen in Exps 1A and 1B. Average blood alcohol concentrations fluctuated with time of day and day of treatment. Average maximum concentration was 91.4 mg ethanol/100 ml serum. In Exp. 2, hybrid mouse 2-cell embryos were cultured in vitro in 0 or 0.1% ethanol (Exp. 2A) and 0 or 1.0% ethanol (Exp. 2B) for 8 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Inequality in function of the right and left ovaries and uterine horns of the mouse.

Inequality in function of the left and right ovaries and uterine horns of mice was evaluated in three separate experiments. In Exp. 1, the effect of position in the reproductive tract on various reproductive characteristics was evaluated in 158 pregnant hybrid mice. Ovulation rate, number of fetuses, total fetal weight and total placental weight were higher (P less than 0.05) on the right than the left on Day 18 of pregnancy (vaginal plug = Day 1). In Exp. 2, the effect of previous sham or unilateral ovariectomy (right or left) in mated Swiss-Webster mice was compared with unoperated mated controls (N = 17-24/treatment). In control mice, ovulation rate, total fetal weight and ovarian weight were higher (P less than 0.05) on the right than left side. Surgery (sham or unilateral, ovariectomy) decreased (P less than 0.005) ovulation rates, number of fetuses, ovarian weights, total fetal weight and total placental weight on Day 18 of pregnancy. Unilateral ovariectomy decreased (P less than 0.05) ovulation rates and ovarian weights more than did sham operation. Ovulation rates were higher (P less than 0.01) when the left ovary was manipulated or removed rather than the right ovary. For Exp. 3, pairs of 8 hybrid mouse embryos each (morulae and blastocysts) were surgically transferred to the left and right uterine horns of the same (bilateral, N = 15) or different (unilateral, N = 28) Swiss-Webster recipients. In almost all incidences, embryo survival (to Day 18 of pregnancy) was twice as high (P less than 0.05) in right than left uterine horns. We conclude that the left and right ovaries and uterine horns are not equal in function in Swiss-Webster and a hybrid strain of mice.

Quality of semen stored in on-the-farm semen tanks.

We assessed the damage to frozen semen packaged in French straws stored for 2 yr in 60 on-the-farm semen tanks on 56 Washington dairy farms. Percentage of motile spermatozoa and percentage of spermatozoa with intact acrosomes were not affected significantly by position of the semen on the rack (top or bottom goblet). The semen in 3 of the 60 tanks was lost to tank failure.