A Utilization Review of Patients That Respond to Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution.

Studies have demonstrated the benefits of LDN for various pain indications. This review describes the utilization of and response to LDN in patients with chronic pain within the William S. Middleton Memorial Veterans Hospital (Madison VA). This was a retrospective, single center, chart review of patients that were prescribed LDN for chronic pain. The primary outcome, change in subjective pain report via numeric rating scale (NRS), was analyzed through Wilcoxon Signed Rank Test and descriptive statistics. A total of 136 participants were included. Patients had an average pain score of 7.1 per NRS at baseline. At the initial follow up visit, participants had an average pain of 6.4 (p < 0.001). Additionally, 17.1% of patients had a greater than or equal to 30% pain reduction from baseline. At subsequent follow up, patients reported an average pain of 5.5 (p < 0.0001) per NRS. At the end of the study, 31.6% of patients were maintained on LDN at an average dose of 3.8 mg. This retrospective review demonstrated that LDN may be an effective modality for some chronic pain indications. Reported pain scores were significantly lower at initial follow up compared to baseline for the total population, and for patients with fibromyalgia (FM) specifically.

Lived Experience-Led Research Agenda to Address Early Death in People With a Diagnosis of a Serious Mental Illness: A Consensus Statement.

Importance: People with serious mental illness (SMI), defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorder, or disabling major depressive disorder) die approximately 10 to 25 years earlier than the general population. Objective: To develop the first-ever lived experience-led research agenda to address early mortality in people with SMI. Evidence Review: A virtual 2-day roundtable comprising 40 individuals convened on May 24 and May 26, 2022, and used a virtual Delphi method to arrive at expert group consensus. Participants responded to 6 rounds of virtual Delphi discussion via email that prioritized research topics and agreement on recommendations. The roundtable was composed of individuals with lived experience of mental health and/or substance misuse, peer support specialists, recovery coaches, parents and caregivers of people with SMI, researchers and clinician-scientists with and without lived experience, policy makers, and patient-led organizations. Twenty-two of 28 (78.6%) of the authors who provided data represented people with lived experiences. Roundtable members were selected by reviewing the peer-reviewed and gray literature on early mortality and SMI, direct email, and snowball sampling. Findings: The following recommendations are presented in order of priority as identified by the roundtable participants: (1) improve the empirical understanding of the direct and indirect social and biological contributions of trauma on morbidity and early mortality; (2) advance the role of family, extended families, and informal supporters; (3) recognize the importance of co-occurring disorders and early mortality; (4) redefine clinical education to reduce stigma and support clinicians through technological advancements to improve diagnostic accuracy; (5) examine outcomes meaningful to people with an SMI diagnosis, such as loneliness and sense of belonging, and stigma and their complex relationship with early mortality; (6) advance the science of pharmaceuticals, drug discovery, and choice in medication use; (7) use precision medicine to inform treatment; and (8) redefine the terms system literacy and health literacy. Conclusions and Relevance: The recommendations of this roundtable are a starting point for changing practice and highlighting lived experience-led research priorities as an option to move the field forward.

Ceftriaxone 1 g Versus 2 g Daily for the Treatment of Enterobacterales Bacteremia: A Retrospective Cohort Study.

Background: Ceftriaxone is a commonly used antibiotic for the treatment of susceptible Enterobacterales infections. There is currently limited clinical data on the optimal dose of ceftriaxone for Enterobacterales bacteremia. Objectives: To evaluate the rate of clinical failure of ceftriaxone 1 g versus 2 g daily in patients with Enterobacterales bacteremia. Methods: This was a retrospective cohort study of patients admitted to any of the 3 New York University Hospitals: Long Island, Tisch, or Brooklyn, with ceftriaxone-susceptible Enterobacterales bacteremia, receiving ceftriaxone 1 or 2 g daily from October 2019 to September 2020. The primary outcome was 90-day rate of clinical failure. Clinical failure was defined as escalation of therapy, relapse of infection, or all-cause mortality. Results: A total of 124 patients, 58% in the 1-g group and 42% in the 2-g group, were included. There was no statistically significant difference found in the primary outcome. The 90-day rate of clinical failure was 16.7% versus 9.6%, P = 0.260. There were no statistically significant secondary outcomes, although infection relapse rates at 90 days were numerically greater in the 1-g group (11.1% vs 1.9%, P = 0.078). Hypoalbuminemia was the only variable associated with an increased risk of clinical failure (odds ratio = 4.03; 95% confidence interval [CI] = 1.12-14.50, P = 0.033). Conclusion: In our exploratory findings, there was no statistically significant difference with the 90-day rate of clinical failure between ceftriaxone 1 g versus 2 g daily, although there was a numeric trend toward an increased rate of infection relapse within the 1-g group. Hypoalbuminemia was associated with an increased risk of clinical failure. Prospective studies are warranted to confirm these findings.

Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital.

OBJECTIVES: To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates. METHODS: This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations. RESULTS: Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation. CONCLUSION: Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.

Characterizing patterns of small pneumoconiotic opacities on chest radiographs of New Mexico coal miners.

Small pneumoconiotic opacities in coal miners are usually described as rounded, regular, and upper zone predominant. We aim to characterize chest radiographic patterns in New Mexico coal miners in comparison with other miners. Of the 330 chest radiographs reviewed, small pneumoconiotic opacities in New Mexico miners were almost always irregularly shaped, and lower lung zone predominant, consistent with diffuse dust-related pulmonary fibrosis. There was no significant difference in patterns of opacities between miners with exposure to coal mine dust exclusively, mixed coal and noncoal mine dust, and no coal dust. Our findings indicate that New Mexico coal miners demonstrate a different pattern of small pneumoconiotic opacities than the classic nodular pneumoconiosis described in the literature, predominantly from Appalachian miners. This may indicate differences in racial/ethnic characteristics or in the silica/silicate content of dust between the Appalachian and Mountain West regions.

Primary Care Shared Medical Appointment for Pain Management: A Pilot Program.

Effective strategies that are evidence-based and non-addictive are needed to manage chronic pain and combat the opioid crisis. One potential strategy is to utilize a shared medical appointment (SMA), which is a model of providing clinical care in a group setting with multiple healthcare team members for comprehensive pain management. The purpose of this retrospective chart review is to evaluate the impact of a pain management SMA at the William S. Middleton Veterans Affairs (VA) West Clinic on opioid use and behaviors. Quantitative and qualitative data was obtained from the electronic medical record of 16 Veterans who participated in the pain SMA and analyzed using descriptive statistics. In addition to a reduction in opioid doses six months post SMA, participants gained non-pharmacological referrals, addition of non-opioid pain medications, and a mix of didactic and experiential education on pharmacologic and non-pharmacologic treatment modalities to help manage their chronic pain. This SMA allowed for greater access to healthcare professionals with a sole focus on pain management and provided Veterans with a holistic approach to their pain management.

Effect of an acute blood donation on oxygen uptake kinetics in moderate and heavy domains over a period of 96 hours.

BACKGROUND: Studies determining the effects of blood donation (BD) on oxygen uptake kinetics are limited. This study aims to ascertain the effects of BD (~470 mL) over a period of 96 hours on oxygen uptake kinetics in moderate and heavy exercise domains. STUDY DESIGN AND METHODS: Twelve participants (nine males and three females; 31.1 ± 11.7 years, mass 79.9 ± 12.8 kg, height 175.5 ± 7.5 cm) completed four consecutive days (24-96 hours) of moderate and heavy V˙O2 on-kinetics trials pre BD and post BD. Visit one (0 hour), pre BD established hematological levels, V˙O2max and Gas Exchange Threshold (GET). Subsequent visits comprised two 6-minute moderate (∆ 50% rest-GET) and 1 heavy (∆ 20% GET-V˙O2max ) trial. Post BD 0 hour the participants donated blood post hematological testing only. RESULTS: Despite non-significances for V˙O2 amplitude, time constant-2 (tau2 ) for V˙O2 showed significant decreases at 24 and 48 hours, and tau3 showed significant increases at 72 and 96 hours pre to post BD (P < .05). Hemoglobin (Hb) values reduced (P < .05) pre (14.48 ± 0.16 g·dL-1 ) to post BD (13.47 ± 0.66 g·dL- 1). Hb significantly decreased at 24, 48, 72, and 96 hours compared to 0 hour post BD (P < .05). CONCLUSION: BD has no effect on V˙O2 amplitude, but time-based components show sensitivity to reduced circulating O2 ; with a decreased PO2 a slower O2 exchange across the blood myocyte barrier could result in altering O2 kinetics.

A Rare Case of HHV-8 Associated Hemophagocytic Lymphohistiocytosis in a Stable HIV Patient.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a rare condition associated with viral infections including HIV. Cases have been reported mainly in advanced HIV/AIDS. This is a rare case that reports HLH associated with human herpes virus-8 (HHV-8) associated multicentric Castleman disease in a stable HIV patient. CASE PRESENTATION: A 70-year-old Asian male patient with history of stable HIV on medications with CD 4 cell count above 200 presented with cough and fever and was initially treated for pneumonia as an outpatient. Persisting symptoms prompted presentation to the hospital. The patient was found to have anemia which persisted despite repeated transfusion of packed red cells. A bone marrow biopsy to investigate anemia revealed hemophagocytosis. A CT scan revealed multiple enlarged lymph nodes and hepatosplenomegaly. An excisional lymph node biopsy revealed HHV-8 associated multicentric Castleman disease. The patient deteriorated despite initiation of treatment. CONCLUSION: HLH can occur at any stage of HIV, rapid diagnosis to identify possible underlying reactive infectious etiology and prompt initiation of treatment is crucial to survival.

The acute effects of whole blood donation on cardiorespiratory and haematological factors in exercise: A systematic review.

BACKGROUND: This systematic review aimed to collect the relevant historical and current literature to produce an informed analysis of the acute effects on cardiorespiratory and haematological factors following whole blood donation (~ 470 ml) during exercise. Testing the hypothesises that blood donation produces either no changes (Null) or produces significant changes (alternate) in haematology, [Formula: see text], heart rate, exercising power and time. METHODS: Four databases of medical and science orientations were searched with terms sensitive to connections regarding exercise, blood donation (400-500 ml)/haematology, [Formula: see text], heart rate, exercising power and time. The study retrieval process utilised the PRISMA approach and selection was via an adapted scoring method according to the Consensus based Standards for the selection of health Measurements Instruments (COSMIN). Systematic review focused on 24-48 hrs post donation. Details of the PRSIMA checklist can be found in the accompanying online document. RESULTS: Following scrutiny of 48 research papers by two independent assessors 8 experimental studies were included. Four studies showed a mean reduction for difference in [Formula: see text] (- 2.4 ± 1.4 ml∙kg-1∙min-1) and a medium effect size (-0.26). No statistical significance was present at the mean meta-analysis level, also the case for heart rate, time to exhaustion and power. A mean reduction was seen in haemoglobin (- 1.05 g.dL-1), haematocrit (- 3.71%) and red blood cells (- 0.44 Mio µL-1), very large effect size was observed (Cohen's d, -0.75, -1.16 and -4.23 respectively) and statistical significance (95% CI, -2.04, -0.54; -4.59, 2.28 and -4.37, -4.10 respectively). CONCLUSION: Although individual studies show that [Formula: see text] Is reduced from blood donation pooled results show that [Formula: see text] is indeed not significantly reduced from blood donation 24-48 hrs post donation. Additionally sub-maximally there isn't enough data to produce substantial comparatives. Furthermore, this systematic review demonstrates that there are not enough high-quality studies regarding cardiorespiratory outcomes following blood donation.

Differences between patient- and professional-reported modified Rankin Scale score in patients with unruptured aneurysms.

OBJECTIVE: Clinical trials forming the basis of current guidelines for the management of intracranial aneurysms have relied on patient-reported modified Rankin Scale (mRS) scores to assess functional outcome. The effect of patient demographics on perception of disability and, by extension, patient-reported mRS score, is not well understood. METHODS: A consecutive series of patients with a previously treated or untreated unruptured intracranial aneurysm (UIA) prospectively underwent a structured interview with a trained nurse. At the conclusion of this interview, the patients were assigned an mRS score in accordance with their degree of disability. During the same visit, patients were also required to grade themselves on a paper sheet containing the mRS and corresponding information. Data on patient and aneurysm characteristics were also collected during the same visit. Agreement between patient- and nurse-reported mRS scores was assessed using Cohen's kappa coefficient. The effect of patient demographics on the frequency of higher patient- than nurse-reported mRS scores was assessed using the Pearson's chi-square and Fisher's exact tests. RESULTS: A total of 209 patients with a UIA were included in the study, 38 of whom (18.2%) had undergone previous treatment. The majority of patients were female (161/209, 77.0%), and the mean age of the cohort was 60.2 years (SD 13.7 years). Agreement between patient- and nurse-reported mRS scores occurred in 72.7% of cases (95% CI 66.3%-78.3%), with a kappa coefficient of 0.58 (95% CI 0.49-0.67). Patients younger than 75 years were more likely to report a higher mRS score than the nurse (19.4% vs 3.4%, p = 0.034). Among female patients, those without a college degree were more likely to report a higher mRS score than the nurse (22.5% vs 9.5%, p = 0.035). CONCLUSIONS: The results suggest that patient demographics may influence perception of disability. These findings should be considered when using patient-reported mRS scores to determine functional outcome.

Fossilized skin reveals coevolution with feathers and metabolism in feathered dinosaurs and early birds.

Feathers are remarkable evolutionary innovations that are associated with complex adaptations of the skin in modern birds. Fossilised feathers in non-avian dinosaurs and basal birds provide insights into feather evolution, but how associated integumentary adaptations evolved is unclear. Here we report the discovery of fossil skin, preserved with remarkable nanoscale fidelity, in three non-avian maniraptoran dinosaurs and a basal bird from the Cretaceous Jehol biota (China). The skin comprises patches of desquamating epidermal corneocytes that preserve a cytoskeletal array of helically coiled α-keratin tonofibrils. This structure confirms that basal birds and non-avian dinosaurs shed small epidermal flakes as in modern mammals and birds, but structural differences imply that these Cretaceous taxa had lower body heat production than modern birds. Feathered epidermis acquired many, but not all, anatomically modern attributes close to the base of the Maniraptora by the Middle Jurassic.

The impact of balance-focused attitudes on job stress: Gender differences evidenced in American and Chinese samples.

Based on gender role expectations model, we examined how balance-focused attitudes would affect job stress by influencing individuals' perceptions of family interference with work (FIW), and investigated whether a gender difference would exist in the relationships among balance-focused attitudes, FIW and job stress. Using two independent samples from the United States and China, we found support for the indirect influence of balance-focused attitudes on job stress, through FIW. Participants with balance-focused attitudes experienced lower levels of job stress as they perceived less interference from family to work. As expected, such indirect effect was more pronounce among male participants, meaning that the male participants benefited more from having balance-focused attitudes. Discussion, theoretical and practical implications are provided.

Fourier transform infrared spectral detection of life in polar subsurface environments and its application to Mars exploration.

Cryptoendolithic lichen communities of the Dry Valleys, Antarctica, survive in an extremely inhospitable environment, finding refuge in microscopic niches where conditions suitable for life exist. Such "within-rock" communities may have evolved on Mars when conditions for life on the surface deteriorated to such an extent that they could no longer survive. Fourier transform infrared spectroscopy of unprepared whole-rock Antarctic Beacon sandstones was used to vertically profile molecular vibrations of fatty acids, proteins, and carboxylic acids created by endolithic communities. Spectral biosignatures were found localized to lichen-rich areas and were absent in crustal regions and the bulk rock substrate. These cryptoendolithic profiles will aid similar spectroscopic investigations of organic biosignatures during future Martian subsurface studies and will help in the identification of similar communities in other localities across the Earth.

Use of a Novel Teaching Method to Increase Knowledge and Adherence to Isolation Procedures.

Adherence to infection prevention precautions is a challenge in many hospitals. The purpose of this study was to determine if an isolation educational program, which included visual demonstrations of cross-contamination during breaks in isolation procedures, increased nursing staff knowledge of and adherence to isolation procedures.

Lack of utility of a decision support system to mitigate delays in admission from the operating room to the postanesthesia care unit.

BACKGROUND: When the phase I postanesthesia care unit (PACU) is at capacity, completed cases need to be held in the operating room (OR), causing a "PACU delay." Statistical methods based on historical data can optimize PACU staffing to achieve the least possible labor cost at a given service level. A decision support process to alert PACU charge nurses that the PACU is at or near maximum census might be effective in lessening the incidence of delays and reducing over-utilized OR time, but only if alerts are timely (i.e., neither too late nor too early to act upon) and the PACU slot can be cleared quickly. We evaluated the maximum potential benefit of such a system, using assumptions deliberately biased toward showing utility. METHODS: We extracted 3 years of electronic PACU data from a tertiary care medical center. At this hospital, PACU admissions were limited by neither inadequate PACU staffing nor insufficient PACU beds. We developed a model decision support system that simulated alerts to the PACU charge nurse. PACU census levels were reconstructed from the data at a 1-minute level of resolution and used to evaluate if subsequent delays would have been prevented by such alerts. The model assumed there was always a patient ready for discharge and an available hospital bed. The time from each alert until the maximum census was exceeded ("alert lead time") was determined. Alerts were judged to have utility if the alert lead time fell between various intervals from 15 or 30 minutes to 60, 75, or 90 minutes after triggering. In addition, utility for reducing over-utilized OR time was assessed using the model by determining if 2 patients arrived from 5 to 15 minutes of each other when the PACU census was at 1 patient less than the maximum census. RESULTS: At most, 23% of alerts arrived 30 to 60 minutes prior to the admission that resulted in the PACU exceeding the specified maximum capacity. When the notification window was extended to 15 to 90 minutes, the maximum utility was <50%. At most, 45% of alerts potentially would have resulted in reassigning the last available PACU slot to 1 OR versus another within 15 minutes of the original assignment. CONCLUSIONS: Despite multiple biases that favored effectiveness, the maximum potential benefit of a decision support system to mitigate PACU delays on the day on the surgery was below the 70% minimum threshold for utility of automated decision support messages, previously established via meta-analysis. Neither reduction in PACU delays nor reassigning promised PACU slots based on reducing over-utilized OR time were realized sufficiently to warrant further development of the system. Based on these results, the only evidence-based method of reducing PACU delays is to adjust PACU staffing and staff scheduling using computational algorithms to match the historical workload (e.g., as developed in 2001).