Changing Prescribing Behavior in the United States: Moving Upstream in Opioid Prescription Education.

In the US, deaths from prescription opioids have quadrupled since 1999, prompting authorities to declare an "opioid abuse" crisis. Rising overdose deaths were attributed to trends in the overprescription of opioids, specifically the strength and duration of the initial prescription. We describe educational interventions designed to control healthcare professionals' (HCPs) opioid prescribing in the wake of this crisis. A review of relevant programs for practicing providers, medical residents, and medical students reveals a focus on educational interventions that we describe, borrowing from sociologist John McKinlay's metaphor for public health interventions, as "downstream." These downstream interventions concentrate on regulating and educating practicing HCPs rather than transforming the training environment for medical students and residents. We draw on theories of behavior change to call for the development of complementary "upstream" educational programs for future practitioners that focus on structural and psychosocial factors and may contribute to more sustainable behavior change outcomes.

The impact of supplemental n-3 long chain polyunsaturated fatty acids and dietary antioxidants on physical performance in postmenopausal women.

OBJECTIVES: Identify relationships and evaluate effects of long chain polyunsaturated fatty acids (LCPUFA) on frailty and physical performance. DESIGN: Randomized, double blind pilot study. SETTING: University General Clinical Research Center. PARTICIPANTS: 126 postmenopausal women. INTERVENTION: 2 fish oil (1.2g eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) or 2 placebo (olive oil) capsules per day for 6 months. All participants received calcium and vitamin D supplements. MEASUREMENTS: Fatty acid levels, frailty assessment, hand grip strength, 8 foot walk, body composition, medical history and co-morbidities, nutrient intake, and inflammatory biomarkers taken at baseline and 6 months. RESULTS: At baseline, those with greater red blood cell (RBC) DHA and DHA/arachidonic acid (AA) presented with less frailty (r = -0.242, p=0.007 and r = -0.254, p=0.004, respectively). Fish oil supplementation resulted in higher RBC DHA and lower AA compared to baseline and placebo (p<0.001) and an improvement in walking speed compared to placebo (3.0±16 vs. -3.5±14, p=0.038). A linear regression model included age, antioxidant intake (selenium and vitamin C), osteoarthritis, frailty phenotype, and tumor necrosis factor alpha (TNFα). The model explained 13.6% of the variance in the change in walking speed. Change in DHA/AA (p=0.01) and TNFα (p=0.039), and selenium intake (p=0.031) had the greatest contribution to change in walking speed. CONCLUSION: Physical performance, measured by change in walking speed, was significantly affected by fish oil supplementation. Dietary intake of antioxidants (selenium and vitamin C) and changes in TNFα also contributed to change in walking speed suggesting LCPUFA may interact with antioxidants and inflammatory response to impact physical performance.

Cell-seeded polyurethane-fibrin structures--a possible system for intervertebral disc regeneration.

Nowadays, intervertebral disc (IVD) degeneration is one of the principal causes of low back pain involving high expense within the health care system. The long-term goal is the development of a medical treatment modality focused on a more biological regeneration of the inner nucleus pulposus (NP). Hence, interest in the endoscopic implantation of an injectable material took center stage in the recent past. We report on the development of a novel polyurethane (PU) scaffold as a mechanically stable carrier system for the reimplantation of expanded autologous IVD-derived cells (disc cells) to stimulate regenerative processes and restore the chondrocyte-like tissue within the NP. Primary human disc cells were seeded into newly developed PU spheroids which were subsequently encapsulated in fibrin hydrogel. The study aims to analyze adhesion properties, proliferation capacity and phenotypic characterization of these cells. Polymerase chain reaction was carried out to detect the expression of genes specifically expressed by native IVD cells. Biochemical analyses showed an increased DNA content, and a progressive enhancement of total collagen and glycosaminoglycans (GAG) was observed during cell culture. The results suggest the synthesis of an appropriate extracellular matrix as well as a stable mRNA expression of chondrogenic and/or NP specific markers. In conclusion, the data presented indicate an alternative medical approach to current treatment options of degenerated IVD tissue.

Prospective PC-interactive pressure algesimetry of post-traumatic neck pain after whiplash injury.

Cervical pain is a prominent symptom in both acute whiplash injury and late whiplash syndrome. However, no systematic analysis of post-traumatic pain development covering several weeks has yet been performed in whiplash patients. It was the aim of the present study to analyse the duration and course of post-traumatic muscle pain due to whiplash injury in a prospective follow-up examination with short investigation intervals. A recovery of initially increased muscle pain after whiplash injury within 1 month was hypothesized. Pressure pain of the splenius and trapezius muscles was recorded using PC-interactive pressure algesimetry. Whiplash patients were investigated during the acute injury stage and after 3, 4, and 6 weeks and compared with matched controls. We found significantly increased pressure pain of the splenius and trapezius muscles in the acute stage of whiplash injury. After 4 weeks patients' scores of pain parameters were comparable to those of healthy control subjects. Within the patient group the first changes of pressure pain were observed within 3 (splenius) and 4 weeks (trapezius). For most patients the recovery dynamics lasted 4-6 weeks. A minority of patients did not show any improvement after 6 weeks. The present study shows that the dynamics of pressure pain due to whiplash injury can be quantified by means of PC-interactive pressure algesimetry. Our results confirm the clinical experience that the acute post-traumatic cervical syndrome normally subsides within weeks.

CPAP compliance: video education may help!

BACKGROUND: CPAP remains the treatment of choice for Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS), but compliance with CPAP is poor. Of many interventions tried to improve CPAP compliance, only education and humidification have been shown to be of benefit. Our purpose was to develop and pilot test a video to enhance patient understanding of obstructive sleep apnea and of the purpose, logistics, and benefits of CPAP use in patients newly diagnosed with OSAHS. A patient's CPAP compliance in the first few weeks after starting its use is predictive of long-term compliance with CPAP treatment. It is imperative that patients grasp at the outset both the severity of OSAHS and the effectiveness of CPAP therapy. METHODS: An educational video script was written based on recommendations for patient educational video materials and covering identified misconceptions about OSAHS and perceived barriers to CPAP use. The videotape is 15 min in length and features two middle-aged males, one African-American and one Euro-American, discussing OSAHS and CPAP in a factory break room. RESULTS: In a randomized two-group design with a control group, patients with newly diagnosed OSAHS, and who viewed the CPAP educational video on their first clinic, were significantly more likely to use their machine and to return for a 1-month clinic visit than were those in the control group. CONCLUSION: Viewing of a patient education video at the initial visit was found to significantly improve the rate of return for the follow-up visit.

Quantification of acute neck pain following whiplash injury by computer-aided pressure algesimetry.

Until now the clinical investigation of cervical pain due to whiplash injury is mainly based on finger palpation. The present study introduces a PC-interactive pressure algesimetry to standardize cervical pain measurement. Pressure pain scores of the splenius and trapezius muscles of 23 patients with an acute cervical syndrome after whiplash injury were compared to those of 24 healthy subjects. The pressure painfulness of neck and shoulder muscles was significantly increased in whiplash patients. The splenii muscles showed an equally increased muscle pain whereas the trapezii muscles showed a left-sided preponderance of painfulness, possibly due to the seat belt position in this group of motor vehicle drivers. The computer-interactive pressure algesimetry enables a standardized and rater-independent quantification of the cervical syndrome with neck and shoulder pain caused by whiplash injury.

Urban and rural differences in the relationship between substance use and violence.

This article examines the relationship between substance use and violence across rural-urban and Appalachian places of residence. The data come from a larger study on the health service use of 637 men who have a history of chronic substance abuse and who were incarcerated in four Kentucky prisons. The findings generally support previous research on substance use and violence but do not support Fischer's (1995) subculture theory of urbanism. Contrary to expectations, the population size of the prisoners' residence was not significantly associated with the prisoners' levels of violent victimization, violence toward others, violence toward intimate partners, or overall violence in the year prior to incarceration. Appalachian residency was also not associated with violence. Recognizing that the effect of substance use on violence perpetrated against others does not vary significantly by urban or rural residence may be helpful for designing violence prevention programs and planning law enforcement efforts.

Contribution of the colmation layer to the elimination of coliphages by slow sand filtration.

River bank or slow sand filtration is a major procedure for processing surface water to drinking water in central europe. In order to model the performance of river bank and slow sand filtration plants, we are studying the different mechanisms by which the elimination of pathogens is realized. An important question concerning the mode of action of slow sand filters and river bank filtration units is the role of the colmation layer or "schmutzdecke" on the elimination of human pathogens. The schmutzdecke is an organic layer which develops at the surface of the sand filter short after the onset of operation. We have inoculated a pilot plant for slow sand filtration with coliphages and determined their rate of breakthrough and their final elimination. In the first experiment, with a colmation layer still missing, the breakthrough of the coliphages in the 80 cm mighty sandy bed amounted to ca. 40 %. In contrast, less than 1 % of coliphages escaped from the filter as the same experiment was repeated two months later, when a substantial colmation layer had developed. Our preliminary conclusions are that the colmation layer is extremely efficient in eliminating of viruses.

On the mechanism of the post-activation depression of the H-reflex in human subjects.

It was demonstrated that the soleus H-reflex was depressed for more than 10 s following a preceding passive dorsiflexion of the ankle joint. This depression was caused by activation of large-diameter afferents with receptors located in the leg muscles, as an ischaemic block of large-diameter fibres just below the knee joint abolished the depression, whereas a similar block just proximal to the ankle joint was ineffective. The depression of the H-reflex was not caused by changes in motoneuronal excitability, as motor-evoked potentials by magnetic brain stimulation were not depressed by the same passive dorsiflexion. Therefore it was concluded that the long-lasting depression is due to mechanisms acting at presynaptic level. The transmission of the monosynaptic Ia excitation from the femoral nerve to soleus motoneurones was not depressed by the ankle dorsiflexion. The depression thus seems to be confined to those afferents that were activated by the conditioning dorsiflexion. In parallel experiments on decerebrate cats, more invasive methods have complemented the indirect techniques used in the experiments on human subjects. A similar long-lasting depression of triceps surae monosynaptic reflexes was evoked by a preceding conditioning stimulation of the triceps surae Ia afferents. This depression was accompanied by a reduction of the monosynaptic Ia excitatory postsynaptic potential recorded intracellularly in triceps surae motoneurones, but not by changes in the input resistance or membrane potential in the motoneurones. Stimulation of separate branches within the triceps surae nerve demonstrated that the depression is confined to those afferents that were activated by the conditioning stimulus. This long-lasting depression was not accompanied by a dorsal root potential. It is concluded that the long-lasting depression is probably caused by a presynaptic effect, but different from the "classical" GABAergic presynaptic inhibition which is widely distributed among afferent fibres and accompanied by dorsal root potentials. It is more probably related to the phenomenon of a reduced transmitter release from previously activated fibres, i.e. a homosynaptic post-activation depression. The consequences of this post-activation depression for the interpretation of results on spinal mechanisms during voluntary movements in man are discussed.

Kentuckians' attitudes toward children with epilepsy.

We explored Kentuckians' attitudes toward children with epilepsy. Questions compared respondents' attitudes about children with epilepsy, asthma, hyperactivity, and AIDS. Random digit dialing led to 617 completed interviews. The key questions asked concerned (a) how a pupil with each illness would alter the classroom environment, and (b) how the condition would affect the child's quality of life (QOL) at age 21 years. Respondents used a 0-10 rating scale (0 = worst, 5 = normal, 10 = best). A dichotomous variable divided respondents into those who rated below and those who rated at or above the norm: 24% predicted a deterioration of the classroom environment with the addition of a pupil with epilepsy (similar to AIDS at 26%); 41% predicted a lessened QOL at age 21 years (a worse rating than either asthma or hyperactivity). We created summary indexes, using difference scores between epilepsy ratings and ratings for the other conditions: Relative Educational Distance (RED) and Relative Quality of Life Distance (RQLD) measures. On the RED index, rural and Appalachian respondents showed the greatest prejudice toward pupils with epilepsy. Conversely, we noted the greatest prejudice in RQLD among urban residents (the best educated group). Our data do not support contentions that prejudices against persons with epilepsy are disappearing.

X-ray kinematography as a tool for investigations of distal limb movements of the cat.

X-ray kinematography was used to investigate the kinematics of cat distal forelimb joints during motor behaviour. These joints are not accessible for instrumentation with external markers normally used in conventional motion analysis systems. To trace the movements in space two X-ray systems positioned rectangularly to each other illuminated the forelimb quasi-simultaneously with pulsed X-ray shots (time resolution: 20 ms). A mathematical model was developed for 3-dimensional reconstruction of the object and includes procedures for correction of image distortions, e.g., pincushion distortions and rotation of the image due to interaction of the earth's magnetic field with the electron optics of the image amplifiers. Accuracy of image correction and object reconstruction is +/- 1 pixel, corresponding to +/- 0.5 mm in space which is sufficient for investigation of the kinematics of cat distal forelimb joints. The approach described is of general relevance and useful in kinematic investigations where the structures under study are not directly accessible to external instrumentation with markers.

Biogenic, psychogenic, and sociogenic models of adjustment to chronic pain: an exploratory study.

OBJECTIVE: Based upon three models of etiology and adjustment in CLBP, predictions were made about the variables that were expected to differentiate organic and nonorganic patients, including: psychological distress (anxiety, depression, stress, alienation), pain condition and treatment, and general health. METHOD: Patients from a medical school orthopedic clinic with an organic (N = 58) or a nonorganic (N = 33) diagnosis for chronic low back pain (CLBP) were compared on medical, psychological and sociodemographic variables. RESULTS: Nonorganic patients exhibited greater emotional distress, contrary to the biogenic model, and nonorganic patients did not exhibit more somatic complaints, contrary to the psychogenic model. Both patterns were consistent with the sociogenic model; nonorganic patients were more distressed, but not because of a greater tendency to somatize. Moreover, modeling was not supported as an explanation of the pain and distress among these patients. CONCLUSIONS: Social anomie may explain why patients without a medically diagnosable cause for their pain are more psychologically distressed.

Electroencephalography and evoked potentials: a PC-based analysis program for laboratory courses in physiology.

A computer program (EEG Analysis) was developed for the preclinical laboratory course in physiology held for medical and dental students. It offers an off-line analysis of a set of typical and frequently occurring physiological and pathological electroencephalogram (EEG) and evoked potential (EP) recordings, which are stored in an IBM-compatible personal computer (PC) system. The users are requested to measure and analyze the data sets and to work through a base of questions relevant in the frame of the particular topic. The program is structured in several exercises: calibration, pickup of non-EEG signals (eye movements, chewing), waveforms in EEG recordings from awake subjects (alpha-waves, beta-waves), desynchronization of cerebral activity (visual activation, acoustic activation, mental activation), habituation of cerebral activity upon acoustic stimuli, EEG recordings from asleep subjects (different sleep stages, sleep-specific EEG signals), epileptic seizures, and EPs (principle of averaging, visually evoked potentials in different cortical areas). The program runs under MS-DOS and is network capable. The software structure ensures maximal flexibility for rapid changes and adaptations of the program to specific needs of a particular EEG course. The program has been used for three years, and the response from > 800 students has been consistently positive.

Obesity stigma reduction in medical students.

The purpose of this study was to develop and evaluate an educational intervention designed to modify the stigma held by first-year medical students towards obese patients. The intervention, composed of video, audio and written components, was based on Petty and Cacioppo's elaboration likelihood model. Prior to the course, the medical students held largely accurate beliefs about the causes of obesity, but they still maintained negative stereotypes of the obese as lazy and lacking in self-control. Analysis of students' attitudes toward obese patients five weeks and one year after the course indicates that the intervention was effective. At the five-week assessment, students in the intervention group differed from students in the control group on six of eight measures of attitudes toward the obese. One year after the course, the intervention group was significantly more likely to rate genetic factors as important in obesity and less likely to blame the obese for their condition.

[Mucociliary clearance in childhood]. / Die mukoziliare Clearance im Kindesalter.

AIM OF THE STUDY: A new, nearly monodisperse human serum albumin particle produced by air-pressure-nebulization was inhaled by children and lung-transplant patients. METHOD: After inhalation of the particles obtained with an air-pressure nebulizer, the initial deposition pattern showed a marked tracheobronchial deposition which could be reproducibly obtained without a special breathing technique, the alveolar deposition being not higher than 10%. With the use of 99mTc, the radiation exposure is limited to a level which is low enough for children, but images can be taken up to 24 hrs later. Further parameters for in vivo characterization of the mucociliary function are the 24 h retention pattern and the velocity of particle motion in the trachea. RESULTS: Within the first 45 minutes, the global clearance rate was 51% in healthy children, which is rather high in comparison with the literature, most likely due to size of particles and the selection of patients with a mean age of 10.7 years. In ciliary dysfunction, the initial clearance rate was 16% and 46% within 24 h. CONCLUSIONS: With simplification of the preparation, application, and examination technique, this method is to be used in children, so that a wider use can be anticipated. The normally fast initial elimination of particles allows quick differentiation of normal and impaired ciliary function.

Limitations of clearance determination using the single sample distribution volume method. An error analysis on the basis of compartment models.

To investigate the error possibly contained in the single sample distribution volume method for the determination of renal clearance, a mathematical model was applied to describe the effect of changes in distribution volume, clearance, intravascular space, intracompartmental exchange and the time point of blood sampling. The method was found to be valid only under well-defined circumstances (Topt = 45 +/- 5 min, Cl = 390 +/- 50 ml/min, Vd = 16.7 +/- 4 l, alpha = 0.05.V1 ml/min, V1/Vd = 0.5 +/- 0.05) as shown in sample calculations. Two-compartment model-based error calculations demonstrate that this technique implies at best an uncertainty of +/- 10% or more. Whilst it can be used preferably in healthy, normal-weight adults, it is not applicable, without error, under all other circumstances.