Fact vs. fiction: naloxone in the treatment of opioid-induced respiratory depression in the current era of synthetic opioids.

Opioid-induced respiratory depression (OIRD) deaths are ~80,000 a year in the US and are a major public health issue. Approximately 90% of fatal opioid-related deaths are due to synthetic opioids such as fentanyl, most of which is illicitly manufactured and distributed either on its own or as an adulterant to other drugs of abuse such as cocaine or methamphetamine. Other potent opioids such as nitazenes are also increasingly present in the illicit drug supply, and xylazine, a veterinary tranquilizer, is a prevalent additive to opioids and other drugs of abuse. Naloxone is the main treatment used to reverse OIRD and is available as nasal sprays, prefilled naloxone injection devices, and generic naloxone for injection. An overdose needs to be treated as soon as possible to avoid death, and synthetic opioids such as fentanyl are up to 50 times more potent than heroin, so the availability of new, higher-dose, 5-mg prefilled injection or 8-mg intranasal spray naloxone preparations are important additions for emergency treatment of OIRDs, especially by lay people in the community. Higher naloxone doses are expected to reverse a synthetic overdose more rapidly and the current formulations are ideal for use by untrained lay people in the community. There are potential concerns about severe withdrawal symptoms, or pulmonary edema from treatment with high-dose naloxone. However, from the perspective of first responders, the balance of risks would point to administration of naloxone at the dose required to combat the overdose where the risk of death is very high. The presence of xylazines as an adulterant complicates the treatment of OIRDs, as naloxone is probably ineffective, although it will reverse the respiratory depression due to the opioid. For these patients, hospitalization is particularly vital. Education about the benefits of naloxone remains important not only in informing people about how to treat emergency OIRDs but also how to obtain naloxone. A call to emergency services is also essential after administering naloxone because, although the patient may revive, they may overdose again later because of the short half-life of naloxone and the long-lasting potency of fentanyl and its analogs.

Using Mathematical Modeling to Improve the Emergency Department Nurse-Scheduling Process.

INTRODUCTION: Nurse scheduling within an emergency department can be a very time-consuming process as nursing leadership works to reach sufficient nurse-staffing levels across every day of the schedule while also working to satisfy nurse preferences. METHODS: A mathematical model is formulated to determine nursing shifts to minimize the number of shifts across a day while accounting for staffing level requirements, nurse preferences, and meal breaks. RESULTS: A daily schedule based on nursing shifts was created and used within the self-scheduling process. Implementing the schedule improved nurse-staffing levels while decreasing the time necessary to reconcile the monthly schedule, resulting in the potential to increase nurse satisfaction. DISCUSSION: The emergency department can use mathematical modeling to improve the nurse-scheduling process.

New Model of Automated Patient-Reported Outcomes Applied in Atrial Fibrillation.

Background The value of patient-reported outcomes (PRO) is increasingly recognized in patient-centered care. Longitudinal data collection may be challenging and cost prohibitive. Automation of PRO collection may complement routine clinical follow-up, especially for procedures aiming to improve quality of life, such as atrial fibrillation (AF) ablation. Methods We aimed to develop a fully automated platform to collect PRO and evaluate its first clinical application in a prospective cohort of AF ablation. The duration of follow-up and data availability were assessed with automated PRO and routine follow-up versus routine follow-up alone (primary outcome). Quality of life and healthcare utilization (secondary outcomes) by PRO were assessed. Results Between 2013 and 2016, 2175 patients were eligible to receive 10 903 PRO assessment invitations, and the automated platform sent all invitations as programmed. More follow-up assessments were obtained with automated PRO and routine follow-up compared with routine follow-up alone (12 859 versus 10 248; P<0.0001) which allowed longer duration of follow-up (378 versus 217 days, 74% increase; P<0.0001). By automated PRO, a large number of disease-specific variables were collected and showed improvement in quality of life (baseline median AF symptom severity score AFSSS of 12 [6-18] and ranged between 2 and 3 on subsequent assessments; P<0.0001). This improvement was also true for each of the AFSSS individual components ( P<0.0001). In PRO, there was a significant reduction in AF burden (such as frequency and duration of episodes; P<0.0001) and associated healthcare utilization (including emergency visits and hospitalizations; P<0.0001) after the ablation procedures. Conclusions A fully automated system for PRO collection enhanced clinical follow-up and allowed collection of disease-specific data when applied in a prospective cohort of AF ablation.

Solute-induced dissolution of hydrophobic ionic liquids in water.

Significant solubilization of ostensibly water-immiscible ionic liquids (ILs) in acidic aqueous phases is induced by the presence of any of a variety of neutral extractants, the apparent result of the formation of the protonated form of the extractant and its subsequent exchange for the cationic component of the IL. The extent of this solubilization is shown to diminish with increasing hydrophobicity of the IL cation and decreasing extractant basicity. These observations raise concerns as to the viability of ILs as "drop in replacements" for traditional organic solvents in the solvent extraction of metal ions.

Fluorous ionic liquids as solvents for the liquid-liquid extraction of metal ions by macrocyclic polyethers.

The predominant mode of strontium ion transfer from aqueous nitrate media into a series of 1-fluoroalkyl-3-methylimidazolium bis[(trifluoromethylsulfonyl)]imides containing dicyclohexano-18-crown-6 (DCH18C6) is shown to shift from cation exchange to strontium nitrato-crown ether complex partitioning as the length of the fluoroalkyl substituent is increased. Fluoroalkyl substituents are shown to be only slightly more effective than their non-fluorous analogs at inducing this shift. At the same time, the fluorinated ionic liquids (ILs) yield strontium distribution ratios as much as an order of magnitude lower than the corresponding 1-alkyl-3-methylimidazolium (C(n)mim(+)) salts. Fluorous ILs thus appear to offer no compelling advantages over C(n)mim(+) ionic liquids as extraction solvents.

Intermolecular (1)H-(1)H Two-Dimensional Nuclear Overhauser Enhancements in the Characterization of a Rationally Designed Chiral Recognition System.

Chiral stationary phases (CSPs) for liquid chromatography derived from N-(acyl)proline-3,5-dimethylanilides separate the enantiomers of N-(3,5-dinitrobenzoyl)-alpha-amino esters and amides with high levels of selectivity. These CSPs have been used to assemble a large body of chromatographic data which indirectly supports the validity of the mechanistic rationale originally used in the design of these CSPs. We herein report (1)H and (13)C chemical shift data obtained when the (S)-enantiomer of chiral solvating agent (CSA) 3, a soluble analogue of the selector used in CSP (S)-1, acts on each of the enantiomers of the dimethylamide of N-(3,5-dinitrobenzoyl)leucine, 2. The changes in chemical shift in the mixture of (S)-2 and (S)-3 support the existence of those interactions thought to be essential to chiral recognition in this system. In addition, significant intermolecular NOESY enhancements are observed in this mixture. These NOE data are consistent with the structure expected for the more stable diastereomeric adsorbate formed between (S)-2 and the (S)-proline-derived CSP 1. No intermolecular NOEs are observed for corresponding mixtures of the chiral solvating agent (S)-3 and (R)-2, the enantiomer least retained on (S)-CSP 1.