Data-Based Opioid Risk Review in Patients with Chronic Pain: A Retrospective Chart Review.

A retrospective, cohort, single center, chart review was conducted to compare rates of opioid-associated serious adverse events (SAEs) in a patient cohort 6 months before and 6 months after data-based opioid risk review. The primary objective was the composite reduction in opioid-related SAEs including suicide-related events and opioid overdoses. The impact of the reviews was assessed via multivariate logistic regression and a McNemar's test to analyze difference in rates of opioid-associated SAEs. This study demonstrates that data-based opioid risk review can reduce opioid-related SAEs, opioid overdoses, and suicide-related events in the 6 months post-review. The primary outcome was not statistically significant with a p-value of 0.080. In the population that underwent opioid tapers, the hazard ratios (HR) for suicide-related events and opioid-related SAEs were 6.64 (1.09-40.53, p = 0.05) and 10.43 (0.48-226.80, p = 0.02) respectively when compared to non-tapered patients. The HR for suicide-related events and opioid-related SAEs when opioid therapy was discontinued were 9.95 (2.16-45.94, p = 0.009) and 15.64 (1.09-225.19, p = 0.001) respectively when compared to continuation of opioids. This study showed that data-based opioid risk review may reduce incidence of opioid-related SAEs in patients with chronic pain. Additionally, opioid tapers and discontinuations are significant risk factors for suicide-related events and opioid-related SAEs.

Interpret with Caution: COPUS Instructional Styles May Not Differ in Terms of Practices That Support Student Learning.

There is a growing need for valid and reliable measures to monitor the efficacy of undergraduate science, technology, engineering, and mathematics (STEM) reform initiatives. The Classroom Observation Protocol for Undergraduate STEM (COPUS) is a widely used tool originally designed to measure the presence of overt instructor and student behaviors. It has subsequently been used to characterize instruction along a continuum from didactic to student centered, and more recently to categorize instruction into one of three styles. Initiatives focused on professional development often support instructors' progression from didactic to student-centered styles. There is a need to examine COPUS instructional styles in terms of behaviors that research has shown to improve student learning. Formative assessment is a research-based practice that involves behaviors accounted for by the COPUS (e.g., posing a question). We qualitatively compared the formative assessment behaviors in 16 biology class sessions categorized into each of the three COPUS styles. We were unable to detect differences in formative assessment behaviors between the COPUS styles. Caution should be taken when interpreting COPUS data to make inferences about the effects of reform efforts. This study underscores the need for additional measures to monitor national reform initiatives in undergraduate STEM.

Can I Have Your Recipe? Using a Fidelity of Implementation (FOI) Framework to Identify the Key Ingredients of Formative Assessment for Learning.

For decades, formative assessment has been identified as a high-impact instructional practice that positively affects student learning. Education reform documents such as Vision and Change: A Call to Action expressly identify frequent, ongoing formative assessment and feedback as a key instructional practice in student-centered learning environments. Historically, effect sizes between 0.4 and 0.7 have been reported for formative assessment experiments. However, more recent meta-analyses have reported much lower effect sizes. It is unclear whether the variability in reported effects is due to formative assessment as an instructional practice in and of itself, differences in how formative assessment was enacted across studies, or other mitigating factors. We propose that application of a fidelity of implementation (FOI) framework to define the critical components of formative assessment will increase the validity of future impact studies. In this Essay, we apply core principles from the FOI literature to hypothesize about the critical components of formative assessment as a high-impact instructional practice. In doing so, we begin the iterative process through which further research can develop valid and reliable measures of the FOI of formative assessment. Such measures are necessary to empirically determine when, how, and under what conditions formative assessment supports student learning.

Assessing cancer risk factors faced by an Ancestral Puebloan population in the North American Southwest.

Ancestral Puebloan people in the North American Southwest suffered high rates of disease, poor health, and early age-at-death. Four individuals with skeletal expressions of cancer were found in a pre-Columbian population in the Taos Valley - Reports of malignant neoplasms in the archaeological record are uncommon and their presence in four of 82 individuals is a high occurrence. This study continues Whitley and Boyer's (2012) research testing whether concentrations of ionizing radiation were sufficiently high to induce cancer and related health issues. Access to a preserved and partly reconstructed subterranean pit structure inhabited between AD 1120 and 1170, allows us to test radon concentrations in a residential dwelling. This study found radon occurring in high levels, 19.4-20.3 pCi/L (717.8-751.1 Bq/m3) within the structure. Epidemiological reports are inconsistent when linking specific cancers and radon exposure. However, this study can control for many of the confounding factors plaguing other studies, provide unique data that have the potential to initiate dialogue on the etiology of neoplastic disease in the American Southwest, and add new dimensions to the study of the living conditions and health of the Ancestral Puebloans and their descendants.

Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures.

BACKGROUND: The outcomes literature on proximal phalanx fractures in children is sparse. The purpose of this study is to report the complications and outcomes of displaced proximal phalanx fractures after treatment with closed reduction and percutaneous pinning (CRPP). METHODS: A retrospective chart review identified 105 patients treated with CRPP of displaced proximal phalanx fractures. Specific complications were recorded for all patients. Thirty-one of these patients returned >1 year after surgery for assessment including visual analogue scales (VAS) of pain level, functional ability, and esthetics. Objective measurements included range of motion, grip and pinch strength, and finger deformity. Radiographs were taken to assess deformity. RESULTS: Five of the 105 patients (4.8%) had a complication including infection, pin site complication, or malunion. Of the entire group, 36 had stiffness and 31 ultimately underwent hand therapy to regain motion. Subcondylar fractures were associated with a greater likelihood of stiffness. In the 31 patients returning for assessment, the median VAS score was 0 for pain (none), function (full), and esthetics (perfect). Range of motion, grip, and pinch strength were equivalent to the contralateral side. Seven of the 31 patients (22.6%) had a measureable coronal plane deviation averaging 5 degrees (range, 3 to 13 degrees) on radiographs. Deviation was associated with subcondylar fractures and a worse esthetic VAS. Deviation was not associated with worse outcomes overall. CONCLUSIONS: Pediatric patients with a displaced proximal phalanx fracture treated with CRPP have an initial notable complication rate related to stiffness; subcondylar proximal phalanx fractures are more commonly affected. At >1-year follow-up, patients had full motion, no pain, and were happy with both function and appearance despite minor deformity in some. These complication data may help better inform patients and families before surgical intervention. LEVEL OF EVIDENCE: Level IV-therapeutic.

Distal radius hemiarthroplasty combined with proximal row carpectomy: case report.

Severe wrist arthritis is most commonly treated by complete wrist arthrodesis, which provides predictable pain relief but the loss of motion may reduce ease of function. In selected patients, motion preserving surgical options, including limited intercarpal fusion, proximal row carpectomy (PRC), and total wrist arthroplasty (TWA) are considered. However, limited fusion and PRC are typically possible only in less severe cases in which there are some articular surfaces showing minimal degeneration that can be retained. TWA is an option for patients who have lower activity demands and specific needs or desires to maintain some wrist motion. Recent utility and decision analysis studies demonstrate that arthroplasty is associated with higher qualify adjusted life year (QALY) than arthrodesis in patients with rheumatoid arthritis. Despite these positive aspects of TWA, the procedure is not as widely accepted as hip, knee, or shoulder arthroplasty. Early implants had problems related to both materials and design, with breakage, loosening and joint imbalance being common complications. Newer generation implants are improved with more predictable early function, less joint imbalance, and rare breakage, but distal component loosening remains a substantial problem. Thus, patients with poor bone stock and those with high activity demands are typically not candidates for TWA, and all patients are advised to restrict activities to reduce the risk of implant loosening. A new motion preserving procedure has recently been used at our institution in selected patients with severe arthritis who do not qualify for TWA but request an alternative to complete wrist fusion. In this procedure, a distal radius implant arthroplasty is combined with a PRC. The distal radius component of a Universal 2 (UNI 2) total wrist arthroplasty system (Integra life Sciences, Plainsboro, NJ) is used. To our knowledge, there have been no previous publications on this technique. We report our first two cases which have shown a satisfactory early outcome for pain relief and functional wrist motion.

In situ detection of nuclear atypia in Barrett's esophagus by using angle-resolved low-coherence interferometry.

BACKGROUND: Monitoring of patients with Barrett's esophagus (BE) for dysplasia, currently done by systematic biopsy, can be improved through increasing the proportion of at-risk tissue examined. OBJECTIVE: Optical biopsy techniques, which do not remove the tissue but interrogate the tissue with light, offer a potential method to improve the monitoring of BE. Frequency-domain angle resolved low-coherence interferometry (fa/LCI) is an optical spectroscopic technique applied through an endoscopic fiber bundle and measures the depth-resolved nuclear morphology of tissue, a key biomarker for identifying dysplasia. The aim of the study was to assess the diagnostic capability of fa/LCI for differentiating healthy and dysplastic tissue in patients with BE. METHODS: Depth-resolved angular scattering data are acquired by using fa/LCI from tissue excised from 3 patients who had esophagogastrectomy. The data are processed to determine the average nuclear size and density as a function of depth beneath the tissue surface. These data are compared with the pathologic classification of the tissue. MAIN OUTCOME MEASUREMENTS: Average of depth-resolved nuclear diameter and nuclear density measurements in tissue samples. RESULTS: Upon comparison to pathologic diagnosis, the fa/LCI data results report the nuclear atypia characteristic of dysplasia in the epithelial tissue. Examination of the average nuclear morphology over the superficial 150 mum results in complete separation between healthy columnar and BE dysplastic tissues. LIMITATIONS: Lack of in vivo data; lack of nondysplastic BE data because of limited sample size. CONCLUSIONS: In complicated tissue structures, such as BE, depth-resolved nuclear morphology measurements provided an excellent means to identify dysplasia. The preliminary results demonstrate the great potential for the in vivo application of fa/LCI as a targeting mechanism for physical biopsy in patients with BE.

Label-free measurement of microbicidal gel thickness using low-coherence interferometry.

Spectral-domain low-coherence interferometry (LCI) was used to measure the thickness of microbicidal gels applied to a cylindrical calibration test socket. Microbicides are topical formulations containing active ingredients targeted to inhibit specific pathogens that are currently under development for application to the epithelial lining of the lower female reproductive tract to combat sexually transmitted infections such as HIV. Understanding the deployment and drug delivery of these formulations is vital to maximizing their effectiveness. Previously, in vivo measurements of microbicidal formulation thickness were assessed using fluorescence measurements of fluorescein-labeled gels via an optical endoscope-based device. Here we present an LCI-based device that measures the thickness of a formulation without the use of any exogenous agents by analyzing the interference pattern generated between the reflections from the front and back surface of the sample. Results are presented that validate the effectiveness and performance of the LCI measurement in a clinically relevant system as compared to an existing fluorescence-based method. The impact of the new LCI-based design on in vivo measurements is discussed.

Fourier-domain angle-resolved low coherence interferometry through an endoscopic fiber bundle for light-scattering spectroscopy.

We present a novel endoscopic fiber bundle probe incorporated in a Fourier-domain angle-resolved low coherence interferometry system for the measurement of depth-resolved angular scattering distributions to permit the determination of scatterer size via elastic scattering properties. Depth resolution is achieved with a superluminescent diode via a Mach-Zehnder interferometer. The sample is illuminated with a collimated beam, and a Fourier plane image of the backscattered light is collected by a coherent fiber bundle. The angular scattering distribution relayed by the fiber bundle is mixed with the reference field and made to coincide with the input slit of an imaging spectrograph. The data collected are processed in real time, producing a depth-resolved angular scattering distribution in 0.37 s. The data are used to determine the sizes of polystyrene microspheres with subwavelength precision and accuracy.