A Qualitative Examination of Opioid Sparing Anesthesia Practices Among CRNAs.

PURPOSE: The purpose of this study was to examine the experiences of CRNAs using opioid sparing techniques in their perioperative anesthesia practice. DESIGN: This study used a qualitative descriptive methodology. METHODS: Semistructured individual interviews were conducted with Certified Registered Nurse Anesthetists who use opioid sparing anesthesia in their clinical practice in the United States. FINDINGS: Sixteen interviews were completed. Thematic network analysis revealed two major themes: (1) perioperative benefits of opioid sparing anesthesia and (2) prospective benefits of opioid sparing anesthesia. Perioperative benefits described include reduction or elimination of postoperative nausea and vomiting, superior pain control, and improved short-term recovery. Prospective benefits described include higher surgeon satisfaction, superior surgeon-managed pain control, increased patient satisfaction, reduction of opioids in the community, and awareness of positive prospective benefits of opioid sparing anesthesia. CONCLUSIONS: This study highlights the significance of opioid sparing anesthesia and its role in comprehensive perioperative pain control, reduction of opioids in the community, and patient recovery beyond the postanesthesia care unit.

What is the Optimal Method Assessing for Persistent Villous Atrophy in Adult Coeliac Disease?

BACKGROUND AND AIMS: Methods of assessing gluten-free diet (GFD) adherence in adults with coeliac disease (CD) include serological testing, dietitian evaluation, questionnaires and repeat duodenal biopsies. Persisting villous atrophy (VA) is associated with CD complications, however gastroscopy with biopsies is expensive and invasive. This study aimed to assess the abilities of a duodenal bulb (D1) biopsy and the Celiac Dietary Adherence Test (CDAT) to detect persisting VA in adults with CD. METHODS: A prospective observational study of adult CD patients referred for follow-up duodenal biopsies was performed. Quadrantic biopsies were taken from the second part of the duodenum (D2), in addition to a D1 biopsy. Patients underwent follow-up serological testing, and completed the CDAT and Biagi Score. These non-invasive adherence markers were compared against duodenal histology. RESULTS: 368 patients (mean age 51.0 years, 70.1% female) had D1 and D2 biopsies taken at follow-up gastroscopy. Compared to D2 biopsies alone, additional D1 biopsies increased detection of VA by 10.4% (p<0.0001). 201 patients (mean age 50.3 years, 67.7% female) completed adherence questionnaires and serology. When detecting VA, sensitivities and specificities of these markers were 39.7% and 94.2% for IgA- tTG, 38.1% and 96.4% for IgA-EMA, 55.6% and 52.2% for CDAT and 20.6% and 96.4% for the Biagi score. CONCLUSIONS: Bulbar biopsies increase detection of persisting VA by 10.4%. Serology, CDAT and Biagi performed poorly when predicting VA. The gold standard for predicting persisting VA remains repeat biopsy.

Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts.

OBJECTIVE: We aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients. DESIGN: The study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD. RESULTS: Cohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively. CONCLUSION: Our results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.

Diagnosing coeliac disease in the elderly: a United Kingdom cohort study.

AIM: To assess the outcomes for an elderly population with coeliac disease and to compare with younger adults with CD. BACKGROUND: Coeliac disease in the elderly has been underdiagnosed due to the heterogeneity of presentation as well as lack of physicians' awareness of CD in this population. However, the benefits of diagnosing CD in the elderly may be contentious. METHODS: Newly diagnosed CD patients were prospectively recruited from the Coeliac Specialist Clinic at the Royal Hallamshire Hospital, Sheffield, between 2008 and 2017. All patients had villous atrophy (VA) on biopsy with positive coeliac serology. Additionally, the patients were retrospectively recruited from 1990 to 2008 to determine the trend in elderly CD diagnostic frequency over time. RESULTS: A total of 1605 patients with CD were recruited (n=644 prospectively, n=961 retrospectively). Of these, 208 patients (13.0%) were diagnosed over the age of 65 years between 1990 and 2017. The proportion of elderly CD diagnoses increased from 0% in 1990-1991 to 18.7% in 2016-2017 (p<0.001). Younger patients more commonly presented with fatigue (p<0.001) and gastrointestinal symptoms including diarrhoea (p=0.005), abdominal pain (p=0.019), and IBS-type symptoms (p=0.008), while older people more frequently presented with B12 deficiency (p=0.037). CONCLUSION: The prevalence of CD in the elderly has significantly increased over the last two decades, but elderly patients tend to present with fewer symptoms. Further research is required to determine whether a strict gluten-free diet in these patients is a necessity or a burden.

A Population Survey of Dietary Attitudes towards Gluten.

It is unclear how the prevalence of people who believe the gluten-free diet (GFD) to be generally healthy ("Lifestylers") is impacting the overall rates of self-reported gluten sensitivity (GS). We repeated a population survey from 2012 in order to examine how attitudes towards GS have changed over time. Our survey (N = 1004) was administered in Sheffield (UK) in 2015, replicating the 2012 experiment. The questionnaire included a food frequency survey and assessed self-reported GS as well as associated variables (prevalence, current diet, pre-existing conditions, etc.). The overall rates of key variables and chi-squared analysis in comparison to the previous survey were as follows: self-reported GS was 32.8% (previously 12.9%, p < 0.001), pre-existing coeliac disease (CD) was 1.2% (previously 0.8%, p = 0.370), following a GFD was 3.7% (previously 3.7%, p = 0.997). Self-reported GS was positively associated with some pre-existing conditions, including anxiety, depression, chronic fatigue, headaches, and other food allergies/intolerances (including irritable bowel syndrome (IBS); chi-squared analyses, all p < 0.001). Over a 3-year period, the fraction of people who self-reported GS increased by over 250%. Despite this, arguably more meaningful indications of underlying physiological GS remained comparable. This research suggests that the public perception of gluten is causing a marked increase in the number of people who erroneously believe they are sensitive to it.

ACTing in Partnership to Accelerate Impact.

Partnership between funders plays a vital role in tackling the AIDS epidemic and can help partners deliver "more than the sum of their parts." But how do partnerships form? How is value leveraged and maximized? How can partnerships achieve policy change? This article addresses these questions through the example of the Accelerating Children's HIV/AIDS Treatment Initiative, an ambitious $200 million public private partnership with a goal of doubling the number of children living with HIV on treatment in 9 priority African countries over a 2-year period. It describes how the partnership formed between the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Children's Investment Fund Foundation (CIFF), and the differing styles, vision, and resources each organization contributed. It also gives examples of policy influence at global level and policy change at national level. Finally, the article considers whether working in partnership was more or less effective than independent funding, with reflections on the value and challenges of collaboration.

"I'M OPENING MY ARMS RATHER THAN PUSHING AWAY:" PERCEIVED BENEFITS OF A MINDFULNESS-BASED INTERVENTION AMONG HOMELESS WOMEN AND YOUNG CHILDREN.

Family homelessness is associated with adverse outcomes in mothers and their young children. Evidence-based programs are needed to support the socioemotional needs of these families. The purpose of this qualitative study was to explore the perceived benefits of participating in a mindfulness program in mother-child dyads receiving services at a therapeutic nursery serving homeless children under the age of 3 years. A convenience sample of 17 predominantly African American mothers participated in in-depth qualitative interviews. Four themes were derived from the data regarding the perceived benefits of the mindfulness program: "me" time, maternal self-regulation, dyadic connectedness, and child well-being. Results demonstrate the perceived benefits of mindfulness on the parent-child relationship and have important implications for families at an increased risk of adverse outcomes. Because homelessness and residential instability confer considerable risk for young children, interventions to support effective parenting are critical.

Prolactin and fMRI response to SKF38393 in the baboon.

Background. This study's goal was to provide dose-response data for a dopamine agonist in the baboon using standard methods (replicate measurements at each dose, across a range of doses), as a standard against which to subsequently validate a novel pharmacological MRI (phMRI) method. Dependent variables were functional MRI (fMRI) data from brain regions selected a priori, and systemic prolactin release. Necessary first steps included estimating the magnitude and time course of prolactin response to anesthesia alone and to various doses of agonist. These first steps ("time course studies") were performed with three agonists, and the results were used to select promising agonists and to guide design details for the single-dose studies needed to generate dose-response curves. Methods. We studied 6 male baboons (Papio anubis) under low-dose isoflurane anesthesia after i.m. ketamine. Time course studies charted the changes in plasma prolactin levels over time after anesthesia alone or after an intravenous (i.v.) dose of the dopamine D 1-like agonists SKF82958 and SKF38393 or the D 2-like agonist pramipexole. In the single-dose dopamine agonist studies, one dose of SKF38393 (ranging from 0.0928-9.28 mg/kg, N = 5 animals) or pramipexole (0.00928-0.2 mg/kg, N = 1) was given i.v. during a 40-min blood oxygen level dependent (BOLD) fMRI session, to determine BOLD and plasma prolactin responses to different drug concentrations. BOLD response was quantified as the area under the time-signal curve for the first 15 min after the start of the drug infusion, compared to the linearly predicted signal from the baseline data before drug. The ED50 (estimated dose that produces 50% of the maximal possible response to drug) for SKF38393 was calculated for the serum prolactin response and for phMRI responses in hypothalamus, pituitary, striatum and midbrain. Results. Prolactin rose 2.4- to 12-fold with anesthesia alone, peaking around 50-90 min after ketamine administration and gradually tapering off but still remaining higher than baseline on isoflurane 3-5 h after ketamine. Baseline prolactin level increased with age. SKF82958 0.1 mg/kg i.v. produced no noticeable change in plasma prolactin concentration. SKF38393 produced a substantial increase in prolactin release that peaked at around 20-30 min and declined to pre-drug levels in about an hour. Pramipexole quickly reduced prolactin levels below baseline, reaching a nadir 2-3 h after infusion. SKF38393 produced clear, dose-responsive BOLD signal changes, and across the four regions, ED50 was estimated at 2.6-8.1 mg/kg. Conclusions. In the baboon, the dopamine D 1 receptor agonist SKF38393 produces clear plasma prolactin and phMRI dose-response curves. Variability in age and a modest sample size limit the precision of the conclusions.