Quality improvement initiative for pain management practices in primary care.

In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.

AAVP Symposium: new approaches in the study of animal parasites.

The following three papers are a very small window onto the types of research being pursued by members of the American Association of Veterinary Parasitologists. They are related by the fact that newer areas in the biology of parasites and their hosts are discussed. The first paper by Dr. Tom Klei, gives a brief view of the interactions between host and parasite of the fascinating organism Wolbachia, a parasite of parasites. The second paper by Dr. Gloria Solano-Aguilar addresses the use of probiotics to alter the host­parasite interface and influence host resistance. The final paper by Dr. Lou Gasbarre outlines an example of integration of the genomics revolution into Veterinary Parasitology. While the subjects are diverse, they demonstrate the vitality of the AAVP.

Cytotoxic effects of peroxynitrite, polymorphonuclear neutrophils, free-radical scavengers, inhibitors of myeloperoxidase, and inhibitors of nitric oxide synthase on bovine mammary secretory epithelial cells.

OBJECTIVE: To determine cytotoxic effects of activated polymorphonuclear neutrophils (PMN) and peroxynitrite on bovine mammary secretory epithelial cells before and after addition of nitric oxide synthase inhibitors, myeloperoxidase (MPO) inhibitors, and free-radical scavengers. SAMPLE POPULATION: Polymorphonuclear neutrophils from 3 lactating cows. PROCEDURE: Cells from the bovine mammary epithelial cell line MAC-T were cultured. Monolayers were treated with activated bovine PMN, lipopolysaccharide (LPS), phorbol 12-myristate 13-acetate (PMA), 3-morpholino-sydnonimine (SIN-1), 4-amino-benzoic acid hydrazide (ABAH), NG-monomethyl-L-arginine, histidine, and superoxide dismutase (SOD). At 24 hours, activity of lactate dehydrogenase in culture medium was used as a relative index of cell death. Tyrosine nitration of proteins in MAC-T cell lysates was determined by visual examination of immunoblots. RESULTS: Lipopolysaccharide, PMA, and < or = 0.1 mM SIN-1 were not toxic to MAC-T cells. Activated PMN, > or = 6 mg of histidine/ml, and 0.5 mM SIN-1 were toxic. Together, histidine and 500,000 activated PMN/ml also were toxic. NG-monomethyl-L-arginine did not have an effect, but ABAH decreased PMN-mediated cytotoxicity. Ten and 50 U of SOD/ml protected MAC-T cells from cytotoxic effects of 0.5 mM SIN-1. Compared with control samples, nitration of MAC-T tyrosine residues decreased after addition of 500,000 PMN/ml or > or = 6 mg of histidine/ml. Superoxide dismutase increased and SIN-1 decreased tyrosine nitration of MAC-T cell proteins in a dose-responsive manner. CONCLUSIONS AND CLINICAL RELEVANCE: Peroxynitrite, MPO, and histidine are toxic to mammary secretory epithelial cells. Superoxide dismutase and inhibition of MPO activity mitigate these effects. Nitration of MAC-T cell tyrosine residues may be positively associated with viability.

A pastoral perspective on pain management.

Describes and illustrates the author's 5Triads of Pastoral Perspective and how it may provide a particular pastoral approach on the understanding of pain and its management. Notes as well various types of complementary resources for managing and coping with pain.

Unsafe sleep practices and an analysis of bedsharing among infants dying suddenly and unexpectedly: results of a four-year, population-based, death-scene investigation study of sudden infant death syndrome and related deaths.

BACKGROUND: Prone sleep and unsafe sleep surfaces increase the risk of sudden infant death. Recent epidemiologic studies also suggest that when an infant's head or face is covered by bedding, or when a sleep surface is shared with others, the risk of dying increases. The inference of a causal role for these risk factors is supported by physiologic studies and by the consistent finding that fewer infants die when risk factors are reduced. The prevalence of most of these risk factors in infant deaths in the United States is uncertain. OBJECTIVE: To describe the prevalence of several important risk factors related to sleep practices among a defined population of infants dying suddenly and unexpectedly. METHODS: In this population-based study, we retrospectively reviewed death-scene information and medical examiners' investigations of deaths in the city of St Louis and St Louis County between January 1, 1994 and December 31, 1997. Because of the potential for diagnostic overlap, all deaths involving infants <2 years old with the diagnoses of sudden infant death syndrome (SIDS), accidental suffocation, or cause undetermined were included. RESULTS: The deaths of 119 infants were studied. Their mean age was 109.3 days (range: 6-350). The diagnoses were SIDS in 88 deaths, accidental suffocation in 16, and undetermined in 15. Infants were found prone in 61.1% of cases and were found on a sleep surface not designed for infants in 75.9%. The head or face was covered by bedding in 29.4%. A shared sleep surface was the site of death in 47.1%. Only 8.4% of deaths involved infants found nonprone and alone, with head and face uncovered. CONCLUSIONS: Using detailed death-scene descriptions, we found that similar unsafe sleeping practices occurred in the large majority of cases diagnosed as SIDS, accidental suffocation, and cause undetermined. Considering these diagnoses together may be useful in public health campaigns during a time when there may be diagnostic overlap. Regardless of the diagnosis, recommendations that infants sleep supine on firm sleep surfaces that lessen the risk of entrapment or head covering have the potential to save many lives. Campaigns are needed to heighten awareness of these messages and of the risks of dangerous bedsharing.