Institutional Trends in Opioid Prescribing and Utilization after Primary Cleft Lip and Palate Repair.

BACKGROUND: Outpatient prescriptions for postoperative pain play an important role in the opioid epidemic. Prescribing guidelines are an effective target for intervention but require procedure-specific data to be successful. The aim of this study was to examine opioid prescribing patterns and pain control after primary cleft lip and palate repair at a large academic center. METHODS: Children undergoing cleft lip and palate repair from April of 2018 to July of 2019 were included in a prospective cohort study. Data on discharge prescriptions, refills, and emergency room visits were obtained from the medical record. Caregivers were surveyed 7 to 21 days after surgery regarding pain control, opioid use, education exposure, storage, and disposal. Chi-square tests and one-way analysis of variance were used to examine predictors of pain control, opioid consumption, safe storage, and disposal. RESULTS: After screening, 59 children were included in the study. Patients were 55.8 percent male with a median age of 12 months (interquartile range, 5 to 15). Ninety percent of patients received an opioid prescription at discharge with a mean quantity of 10 doses (interquartile range, 5 to 15). Ninety-seven percent of caregivers used adjunct medication. Opioids were given for a median of 3 days (interquartile range, 2 to 6.5). Seventy-six percent of caregivers gave less opioid than prescribed. There was no association between pain control and opioid quantity ( p = 0.68). Twenty-four percent of caregivers used locked storage. Thirty-four percent of respondents with leftover medication reported disposal. CONCLUSIONS: Opioids are often overprescribed after cleft lip and palate repair. Providers should consider limiting prescriptions to a 3-day supply to help reduce the quantity of opioids available in the community.

Association of Opioid Quantity and Caregiver Education with Pain Control after Pediatric Tonsillectomy.

OBJECTIVE: To examine whether a service guideline reducing postoperative opioid prescription quantities and caregiver-reported education to use nonopioid analgesics first are associated with caregiver-reported pain control after pediatric tonsillectomy. STUDY DESIGN: Prospective cohort study (July 2018-April 2019). SETTING: Pediatric otolaryngology service at a tertiary academic children's hospital. SUBJECTS AND METHODS: Caregivers of patients aged 1 to 11 years undergoing tonsillectomy (N = 764) were surveyed 7 to 21 days after surgery regarding pain control, education to use nonopioid analgesics first, and opioid use. Respondents who were not prescribed opioids or had missing data were excluded. Logistic regression modeled caregiver-reported pain control as a function of service guideline implementation (December 2018) recommending 20 rather than 30 doses for postoperative opioid prescriptions and caregiver-reported analgesic education, adjusting for patient demographics. RESULTS: Among 430 respondents (56% response), 387 patients were included. The sample was 43% female with a mean age of 5.0 years (SD, 2.5). Pain control was reported as good (226 respondents, 58%) or adequate/poor (161 respondents, 42%). Mean opioid prescription quantity was 27 doses (SD, 7.9) before and 21 doses (SD, 6.1) after guideline implementation (P < .001). Education to use nonopioids first was reported by 308 respondents (80%). In regression, prescribing guideline implementation was not associated with pain control (adjusted odds ratio, 1.3; 95% CI, 0.9-2.0; P = .22), but caregiver-reported education to use nonopioids first was associated with a higher odds of good pain control (adjusted odds ratio, 1.9; 95% CI, 1.1-3.2; P = .02). CONCLUSION: Caregiver education to use nonopioid analgesics first may be a modifiable health care practice to improve pain control as postoperative opioid prescription quantities are reduced.

Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children.

IMPORTANCE: Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced. OBJECTIVE: To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids. DESIGN, SETTING, AND PARTICIPANTS: This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children. MAIN OUTCOMES AND MEASURES: The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids. RESULTS: Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications. CONCLUSIONS AND RELEVANCE: These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

Comparing the Performance of Bread and Breakfast Cereals, Dairy, and Meat in Nutritionally Balanced and Sustainable Diets.

Objective: To quantify the performance of food products in a sustainable diet based on the balance of their contribution to nutrient intake and environmental impact, within the context of the Dutch diet. Design: While fixing the quantity of a specific food group at different levels, optimized diets that met nutrient requirements and stayed as close as possible to the current Dutch diet were calculated, in order to understand its potential environmental impact and its nutritional quality. Bread & breakfast cereals, dairy, and meat were compared between 0 and 250% of current intake. Their performance is expressed in the relationship between the quantity of these food products and (1) the environmental impact of diets and (2) the nutrient balance of the diets. Setting: The Netherlands. Subjects: Women aged 31-50. Results: The amount of bread & breakfast cereals in the optimized diets were inversely correlated with their environmental impact. The nutrient balance of the optimized diets was maintained despite varying cereal content, with the expected improvement over the current diet. Increasing amounts of dairy in the optimized diet were associated with an increase in environmental impact and meat with a steep increase. The nutrient balance of optimized diets with varying dairy and meat contents was also maintained at high levels, even at 0% content. Conclusions: Bread and breakfast cereals are sources of nutrients with a better environmental performance compared to dairy or meat within the context of the Dutch diet. It is possible to optimize diets for environmental impact whilst maintaining a high nutrient balance.

Nutrition in the Bin: A Nutritional and Environmental Assessment of Food Wasted in the UK.

The UK currently has the most detailed, directly measured data for food wasted in the home. This includes information on the exact types of food wasted. These data allow calculation of the nutrients within that waste, as well as its environmental impact. The results progress the conversation beyond how much food is wasted or its energy content; it permits the implications for nutrition and sustainability to be assessed in detail. Data for UK household food waste were expressed as an average waste per capita for each type of food. Each food type was matched with an item (or group of items) from the UK Composition of Foods (7th Ed). The level of nutrients wasted was compared to UK Reference Nutrient Intakes (RNIs) for adult women (19-50 years, used as a proxy for general population requirements). The data were normalized into "nutrient days" wasted per capita per year, then into the number of complete diet days (for 21 nutrients plus energy). Results show that approximately 42 daily diets were discarded per capita per year. By individual nutrient, the highest losses were vitamin B12, vitamin C, and thiamin (160, 140, and 130 nutrient days/capita/year, respectively). For protein, dietary energy and carbohydrates, 88, 59, and 53 nutrient days/capita/year, respectively, were lost. Substantial losses were also found for under-consumed nutrients in the UK: calcium, which was mostly lost via bakery (27%) and dairy/eggs (27%). Food folate was mainly lost through fresh vegetables/salads (40%) and bakery (18%), as was dietary fiber (31 and 29%, respectively). Environmental impacts were distributed over the food groups, with wasted meat and fish the single largest contribution. For all environmental impacts studied, the largest contribution came from agricultural production. This paper shows that there are areas where interventions preventing food waste and promoting healthy eating could work together (e.g., encouraging consumption of vegetables or tackling overbuying, especially of unhealthy foods). Food manufacturers and retailers, alongside governments and NGOs, have a key role to minimize waste of environmentally impactful, nutrient-dense foods, for instance, by helping influence people's behaviors with appropriate formulation of products, packaging, portioning, use of promotions, or public education.

The effect of acute dark chocolate consumption on carbohydrate metabolism and performance during rest and exercise.

Consumption of cocoa-enriched dark chocolate (DC) has been shown to alter glucose and insulin concentration during rest and exercise compared with cocoa-depleted control (CON). However, the impact of DC consumption on exercise metabolism and performance is uncertain. Therefore, we investigated carbohydrate metabolism via stable isotope tracer techniques during exercise after subjects ingested either DC or CON. Sixteen overnight-fasted male cyclists performed a single-blinded, randomized, crossover design trial, after consuming either DC or CON at 2 h prior to 2.5 h of steady-state (SS) exercise (∼45% peak oxygen uptake). This was followed by an ∼15-min time-trial (TT) and 60 min of recovery. [6,6-(2)H2]Glucose and [U-(13)C]glucose were infused during SS to assess glucose rate of appearance (Ra) and disappearance (Rd). After DC consumption, plasma (-)-glucose and insulin concentrations were significantly (p < 0.001) elevated throughout vs. CON. During SS, there was no difference in [6,6-(2)H2]glucose Ra between treatments, but towards the end of SS (last 60 min) there was a ∼16% decrease in Rd in DC vs. CON (p < 0.05). Accordingly, after DC there was an ∼18% significant decrease in plasma glucose oxidation (trial effect; p = 0.032), and an ∼15% increase in tracer-derived muscle glycogen utilization (p = 0.045) late during SS exercise. The higher blood glucose concentrations during exercise and recovery after DC consumption coincided with high concentrations of epicatechin and (or) theobromine. In summary, DC consumption altered muscle carbohydrate partitioning, between muscle glucose uptake and glycogen oxidation, but did not effect cycling TT performance.

The effect of acute pre-exercise dark chocolate consumption on plasma antioxidant status, oxidative stress and immunoendocrine responses to prolonged exercise.

PURPOSE: Acute antioxidant supplementation may modulate oxidative stress and some immune perturbations that typically occur following prolonged exercise. The aims of the present study were to examine the effects of acutely consuming dark chocolate (high polyphenol content) on plasma antioxidant capacity, markers of oxidative stress and immunoendocrine responses to prolonged exercise. METHODS: Fourteen healthy men cycled for 2.5 h at ~60% maximal oxygen uptake 2 h after consuming 100 g dark chocolate (DC), an isomacronutrient control bar (CC) or neither (BL) in a randomised-counterbalanced design. RESULTS: DC enhanced pre-exercise antioxidant status (P = 0.003) and reduced by trend (P = 0.088) 1 h post-exercise plasma free [F2-isoprostane] compared with CC (also, [F2-isoprostane] increased post-exercise in CC and BL but not DC trials). Plasma insulin concentration was significantly higher pre-exercise (P = 0.012) and 1 h post-exercise (P = 0.026) in the DC compared with the CC trial. There was a better maintenance of plasma glucose concentration on the DC trial (2-way ANOVA trial × time interaction P = 0.001), which decreased post-exercise in all trials but was significantly higher 1 h post-exercise (P = 0.039) in the DC trial. There were no between trial differences in the temporal responses (trial × time interactions all P > 0.05) of hypothalamic-pituitary-adrenal axis stress hormones, plasma interleukin-6, the magnitude of leukocytosis and neutrophilia and changes in neutrophil function. CONCLUSION: Acute DC consumption may affect insulin, glucose, antioxidant status and oxidative stress responses, but has minimal effects on immunoendocrine responses, to prolonged exercise.

Predictive relationship between polyphenol and nonfat cocoa solids content of chocolate.

Chocolate is often labeled with percent cocoa solids content. It is assumed that higher cocoa solids contents are indicative of higher polyphenol concentrations, which have potential health benefits. However, cocoa solids include polyphenol-free cocoa butter and polyphenol-rich nonfat cocoa solids (NFCS). In this study the strength of the relationship between NFCS content (estimated by theobromine as a proxy) and polyphenol content was tested in chocolate samples with labeled cocoa solids contents in the range of 20-100%, grouped as dark (n = 46), milk (n = 8), and those chocolates containing inclusions such as wafers or nuts (n = 15). The relationship was calculated with regard to both total polyphenol content and individual polyphenols. In dark chocolates, NFCS is linearly related to total polyphenols (r2 = 0.73). Total polyphenol content appears to be systematically slightly higher for milk chocolates than estimated by the dark chocolate model, whereas for chocolates containing other ingredients, the estimates fall close to or slightly below the model results. This shows that extra components such as milk, wafers, or nuts might influence the measurements of both theobromine and polyphenol contents. For each of the six main polyphenols (as well as their sum), the relationship with the estimated NFCS was much lower than for total polyphenols (r2 < 0.40), but these relationships were independent of the nature of the chocolate type, indicating that they might still have some predictive capabilities.

Cocoa and health: a decade of research.

It has been over 10 years since the first mention in a medical journal about cocoa and chocolate as potential sources of antioxidants for health. During this time, cocoa has been found to improve antioxidant status, reduce inflammation and correlate with reduced heart disease risk; with these results, and its popularity, it has received wide coverage in the press. However, after 10 years of research, what is known about the potential health benefits of cocoa and what are the important next steps in understanding this decadent source of antioxidants?

Dark chocolate improves coronary vasomotion and reduces platelet reactivity.

BACKGROUND: Dark chocolate has potent antioxidant properties. Coronary atherosclerosis is promoted by impaired endothelial function and increased platelet activation. Traditional risk factors, high oxidative stress, and reduced antioxidant defenses play a crucial role in the pathogenesis of atherosclerosis, particularly in transplanted hearts. Thus, flavonoid-rich dark chocolate holds the potential to have a beneficial impact on graft atherosclerosis. METHODS AND RESULTS: We assessed the effect of flavonoid-rich dark chocolate compared with cocoa-free control chocolate on coronary vascular and platelet function in 22 heart transplant recipients in a double-blind, randomized study. Coronary vasomotion was assessed with quantitative coronary angiography and cold pressor testing before and 2 hours after ingestion of 40 g of dark (70% cocoa) chocolate or control chocolate, respectively. Two hours after ingestion of flavonoid-rich dark chocolate, coronary artery diameter was increased significantly (from 2.36+/-0.51 to 2.51+/-0.59 mm, P<0.01), whereas it remained unchanged after control chocolate. Endothelium-dependent coronary vasomotion improved significantly after dark chocolate (4.5+/-11.4% versus -4.3+/-11.7% in the placebo group, P=0.01). Platelet adhesion decreased from 4.9+/-1.1% to 3.8+/-0.8% (P=0.04) in the dark chocolate group but remained unchanged in the control group. CONCLUSIONS: Dark chocolate induces coronary vasodilation, improves coronary vascular function, and decreases platelet adhesion 2 hours after consumption. These immediate beneficial effects were paralleled by a significant reduction of serum oxidative stress and were positively correlated with changes in serum epicatechin concentration.

Rapid reversed phase ultra-performance liquid chromatography analysis of the major cocoa polyphenols and inter-relationships of their concentrations in chocolate.

Chocolate and other cocoa-containing products are a rich source of polyphenols. This paper describes an ultra-performance liquid chromatography (UPLC) method that can separate and quantify in 3 min six of the major chocolate polyphenols: catechin; epicatechin; B2 (epicatechin-4beta-8-epicatechin); B5 (epicatechin-4beta-6-epicatechin); C1 (epicatechin-4beta-8-epicatechin-4beta-8-epicatechin); and tetramer D (epicatechin-4beta-8-epicatechin-4beta-8-epicatechin-4beta-8-epicatechin). A survey of 68 chocolate samples indicated that there was a strongly predictive relationship between epicatechin and the other individual polyphenols, especially procyanidin B2 (R 2 = 0.989), even though the chocolates came from varied sources and manufacturers. The relationship was less strong with catechin, and so further work to explore the reasons for this difference was performed. Chiral analysis on a subset of 23 chocolates showed that (-)-epicatechin had a predictive relationship with (+)-catechin in line with the other polyphenols, but not with (-)-catechin (the predominant form). This indicates that (-)-catechin is the most affected by manufacturing conditions, possibly formed through epimerization from (-)-epicatechin during processing. The results show that epicatechin concentrations can be used to predict the content of other polyphenols, especially B2 and C1, and total polyphenols content. Finally, the (-)-catechin content is not predictable from the epicatechin content, and it is concluded that this is the main form of polyphenol that varies according to manufacturing conditions and cocoa origin.

Postural effects when cycling in late pregnancy.

AIM: This study assessed if upright cycling is preferable to semi-recumbent cycling during pregnancy. METHOD: Healthy women with low risk singleton pregnancies were tested at 34-38 weeks gestation. They cycled for 12 min, either semi-recumbent (45 degrees, n = 27) or upright (n = 23), at 135-145 beats min(-1). RESULTS: When semi-recumbent, minute ventilation was greater (p<0.03) at rest and systolic blood pressure and pulse pressure were greater during exercise (p<0.05). Exercise maternal heart rate, oxygen consumption, oxygen consumption per kilogram, minute ventilation, cardiac output, stroke volume, mean and diastolic blood pressures and arterio-venous oxygen difference were posture-independent. All increased with exercise (p<0.01), except stroke volume when semi-recumbent (p>0.05). Small post-exercise fetal heart rate increases (by 8 beats min(-1), p<0.05) were similar in both postures (n = 11 in each sub-group), with no adverse changes. Fetal heart rate accelerations and uterine activity (n = 11 in each sub-group) were not influenced by posture or exercise. CONCLUSIONS: (1) Neither posture had a distinct advantage. (2) Both postures were safe for short duration cycling. (3) The same target maternal heart rates are suitable for both postures because they resulted in similar oxygen consumptions and fetal heart rates.

(+)-Catechin is more bioavailable than (-)-catechin: relevance to the bioavailability of catechin from cocoa.

Catechin is a flavonoid present in fruits, wine and cocoa products. Most foods contain the (+)-enantiomer of catechin but chocolate mainly contains ( - )-catechin, in addition to its major flavanol, ( - )-epicatechin. Previous studies have shown poor bioavailability of catechin when consumed in chocolate. We compared the absorption of ( - ) and (+)-catechin after in situ perfusion of 10, 30 or 50 micromol/l of each catechin enantiomer in the jejunum and ileum in the rat. We also assayed 23 samples of chocolate for (+) and ( - )-catechin. Samples were analyzed using HPLC with a Cyclobond I-2000 RSP chiral column. At all concentrations studied, the intestinal absorption of ( - )-catechin was lower than the intestinal absorption of (+)-catechin (p < 0.01). Plasma concentrations of ( - )-catechin were significantly reduced compared to (+)-catechin (p < 0.05). The mean concentration of ( - )-catechin in chocolate was 218 +/- 126 mg/kg compared to 25 +/- 15 mg/kg (+)-catechin. Our findings provide an explanation for the poor bioavailability of catechin when consumed in chocolate or other cocoa containing products.

Massive calcium pyrophosphate dihydrate crystal deposition disease: a cause of pain of the temporomandibular joint.

Calcium pyrophosphate dihydrate deposition (CPDD) disease is a disorder that occasionally affects the temporomandibular joint (TMJ) and temporal bone, causing pain (66.6% of cases), swelling (50%), trismus (36.8%), and hearing loss (22.2%). Diagnosis of CPDD is challenging because clinical symptoms and imaging features are not characteristic and may mimic a chondrosarcoma. When the diagnosis of CPDD of the TMJ is under consideration, conventional radiographs of the wrist or the knee may contribute to the final diagnosis. Imaging features of CPDD are discussed with a review of the literature.

Wine polyphenols and promotion of cardiac health.

Wine polyphenols are considered to have beneficial effects on CHD and atherosclerosis. The consumption of red wine is high in Italy and France, approximately four times greater than that in the UK. This disparity in red wine consumption is thought to be the reason for the 'French paradox', where France was shown to have a coronary mortality rate close to that of China or Japan despite saturated fat intakes and cholesterol levels similar to the UK and USA. In the present review, we discuss the effects of wine and some of its polyphenol constituents on early pathological indicators of CHD such as plasma lipids, the endothelium and vasculature, platelets and serum antioxidant activity. The review also examines whether the polyphenols or the alcohol in wine is responsible for the effects on markers of heart disease. The present review concludes that red wine polyphenols have little effect on plasma lipid concentrations but wine consumption appears to reduce the susceptibility of LDL to oxidation and increase serum antioxidant capacity. However, these effects do depend on the amount of wine and period of supplementation. Authors who have examined specific polyphenols suggest that some phenolics appear to have endothelium-dependent vaso-relaxing abilities and some a positive effect on NO concentrations. Red wine phenolics also have an inhibitory effect on platelet aggregation, and individual phenolics also have a similar effect in vitro, although it should be noted that there are often discrepancies as large as ten-fold between the concentrations of polyphenolics tested in vitro and their measured levels in vivo. Evidence suggests that alcohol has a positive synergistic effect with wine polyphenols on some atherosclerotic risk factors. Thus evidence that wine drinking is beneficial for cardiac health continues to accumulate but more research is required to understand fully and exactly the functions of red wine polyphenols.