Summary Objective The relationship between arthroplasty and long-term opioid use in patients with knee or hip osteoarthritis is not well studied. We examined the prevalence, patterns and predictors ...of persistent opioid use after hip or knee arthroplasty. Method Using claims data (2004–2013) from a US commercial health plan, we identified adults who underwent hip or knee arthroplasty and filled ≥1 opioid prescription within 30 days after the surgery. We defined persistent opioid users as patients who filled ≥1 opioid prescription every month during the 1-year postoperative period based on group-based trajectory models. Multivariable logistic regression was used to determine preoperative predictors of persistent opioid use after surgery. Results We identified 57,545 patients who underwent hip or knee arthroplasty. The mean ± SD age was 61.5 ± 7.8 years and 87.1% had any opioid use preoperatively. Overall, 7.6% persistently used opioids after the surgery. Among patients who used opioids in 80% of the time for ≥4 months preoperatively ( n = 3023), 72.1% became persistent users. In multivariable analysis, knee arthroplasty vs hip, a longer hospitalization stay, discharge to a rehabilitation facility, preoperative opioid use (e.g., a longer duration and greater dosage and frequency), a higher comorbidity score, back pain, rheumatoid arthritis, fibromyalgia, migraine and smoking, and benzodiazepine use at baseline were strong predictors for persistent opioid use (C-statistic = 0.917). Conclusion Over 7% of patients persistently used opioids in the year after hip or knee arthroplasty. Given the adverse health effects of persistent opioid use, strategies need to be developed to prevent persistent opioid use after this common surgery.
Massive stars end their lives in explosions with kinetic energies on the order of 1051 erg. Immediately after the explosion has been launched, a region of low density and high entropy forms behind ...the ejecta, which is continuously subject to neutrino heating. The neutrinos emitted from the remnant at the center, the protoneutron star (PNS), heat the material above the PNS surface. This heat is partly converted into kinetic energy, and the material accelerates to an outflow that is known as the neutrino-driven wind. For the first time we simulate the collapse, bounce, explosion, and the neutrino-driven wind phases consistently over more than 20 s. Our numerical model is based on spherically symmetric general relativistic radiation hydrodynamics using spectral three-flavor Boltzmann neutrino transport. In simulations where no explosions are obtained naturally, we model neutrino-driven explosions for low- and intermediate-mass Fe-core progenitor stars by enhancing the charged current reaction rates. In the case of a special progenitor star, the 8.8 $M_\odot$ O-Ne-Mg-core, the explosion in spherical symmetry was obtained without enhanced opacities. The post-explosion evolution is in qualitative agreement with static steady-state and parametrized dynamic models of the neutrino-driven wind. On the other hand, we generally find lower neutrino luminosities and mean neutrino energies, as well as a different evolutionary behavior of the neutrino luminosities and mean neutrino energies. The neutrino-driven wind is proton-rich for more than 10 s and the contraction of the PNS differs from the assumptions made for the conditions at the inner boundary in previous neutrino-driven wind studies. Despite the moderately high entropies of about 100 kB/baryon and the fast expansion timescales, the conditions found in our models are unlikely to favor r-process nucleosynthesis. The simulations are carried out until the neutrino-driven wind settles down to a quasi-stationary state. About 5 s after the bounce, the peak temperature inside the PNS already starts to decrease because of the continued deleptonization. This moment determines the beginning of a cooling phase dominated by the emission of neutrinos. We discuss the physical conditions of the quasi-static PNS evolution and take the effects of deleptonization and mass accretion from early fallback into account.
Fine particulate matter (PM2.5) from U.S. anthropogenic sources is decreasing. However, previous studies have predicted that PM2.5 emissions from wildfires will increase in the midcentury to next ...century, potentially offsetting improvements gained by continued reductions in anthropogenic emissions. Therefore, some regions could experience worse air quality, degraded visibility, and increases in population‐level exposure. We use global climate model simulations to estimate the impacts of changing fire emissions on air quality, visibility, and premature deaths in the middle and late 21st century. We find that PM2.5 concentrations will decrease overall in the contiguous United States (CONUS) due to decreasing anthropogenic emissions (total PM2.5 decreases by 3% in Representative Concentration Pathway RCP 8.5 and 34% in RCP4.5 by 2100), but increasing fire‐related PM2.5 (fire‐related PM2.5 increases by 55% in RCP4.5 and 190% in RCP8.5 by 2100) offsets these benefits and causes increases in total PM2.5 in some regions. We predict that the average visibility will improve across the CONUS, but fire‐related PM2.5 will reduce visibility on the worst days in western and southeastern U.S. regions. We estimate that the number of deaths attributable to total PM2.5 will decrease in both the RCP4.5 and RCP8.5 scenarios (from 6% to 4–5%), but the absolute number of premature deaths attributable to fire‐related PM2.5 will double compared to early 21st century. We provide the first estimates of future smoke health and visibility impacts using a prognostic land‐fire model. Our results suggest the importance of using realistic fire emissions in future air quality projections.
Key Points
We provide the first estimates of future smoke health and visibility impacts in the contiguous United States using a prognostic land‐fire model
Average visibility will improve across the contiguous United States, but fire PM will reduce visibility on the worst days in western and southeastern U.S. regions
The number of deaths attributable to total PM2.5 will decrease, but the number attributable to fire‐related PM2.5 will double by late 21st century
Changes in intensity and frequency of daily heavy precipitation and hot temperature extremes are analyzed in Swiss observations for the years 1901–2014/2015. A spatial pooling of temperature and ...precipitation stations is applied to analyze the emergence of trends. Over 90% of the series show increases in heavy precipitation intensity, expressed as annual maximum daily precipitation (mean change: +10.4% 100 years−1; 31% significant, p < 0.05) and in heavy precipitation frequency, expressed as the number of events greater than the 99th percentile of daily precipitation (mean change: +26.5% 100 years−1; 35% significant, p < 0.05). The intensity of heavy precipitation increases on average by 7.7% K−1 smoothed Swiss annual mean temperature, a value close to the Clausius‐Clapeyron scaling. The hottest day and week of the year have warmed by 1.6 K to 2.3 K depending on the region, while the Swiss annual mean temperature increased by 1.9 K. The frequency of very hot days exceeding the 99th percentile of daily maximum temperature has more than tripled. Despite considerable local internal variability, increasing trends in heavy precipitation and hot temperature extremes are now found at most Swiss stations. The identified trends are unlikely to be random and are consistent with climate model projections, with theoretical understanding of a human‐induced change in the energy budget and water cycle and with detection and attribution studies of extremes on larger scales.
Key Points
Increases in 1901‐2014 daily heavy precipitation intensity and frequency for >90% of Swiss stations
Hottest day/week warmed by 1.6–2.3 K, the frequency of very hot days more than tripled since 1901
Observed trends consistent with model projections and physical understanding
Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease developing towards the end of pregnancy or in the months following delivery in previously healthy women in terms of cardiac ...disease. Enhanced oxidative stress and the subsequent cleavage of the nursing hormone Prolactin into an anti-angiogenic 16 kDa subfragment emerged as a potential causal factor of the disease. We established a prospective registry with confirmed PPCM present in 115 patients (mean baseline left ventricular ejection fraction, LVEF: 27 ± 9 %). Follow-up data (6 ± 3 months) showed LVEF improvement in 85 % and full recovery in 47 % while 15 % failed to recover with death in 2 % of patients. A positive family history of cardiomyopathy was present in 16.5 %. Pregnancy-associated hypertension was associated with a better outcome while a baseline LVEF ≤ 25 % was associated with a worse outcome. A high recovery rate (96 %) was observed in patients obtaining combination therapy with beta-blocker, angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor-blockers (ARBs) and bromocriptine. Increased serum levels of Cathepsin D, the enzyme that generates 16 kDa Prolactin, miR-146a, a direct target of 16 kDa Prolactin, N-terminal-pro-brain-natriuretic peptide (NT-proBNP) and asymmetric dimethylarginine (ADMA) emerged as biomarkers for PPCM. In conclusion, low baseline LVEF is a predictor for poor outcome while pregnancy-induced hypertensive disorders are associated with a better outcome in this European PPCM cohort. The high recovery rate in this collective is associated with a treatment concept using beta-blockers, ACE inhibitors/ARBs and bromocriptine. Increased levels of Cathepsin D activity, miR-146a and ADMA in serum of PPCM patients support the pathophysiological role of 16 kDa Prolactin for PPCM and may be used as a specific diagnostic marker profile.
Astrophysical observations originate from matter that interacts with radiation or transported particles. We develop a pragmatic approximation in order to enable multidimensional simulations with ...basic spectral radiative transfer when the available computational resources are not sufficient to solve the complete Boltzmann transport equation. The distribution function of the transported particles is decomposed into a trapped particle component and a streaming particle component. Their separate evolution equations are coupled by a source term that converts trapped particles into streaming particles. We determine this source term by requiring the correct diffusion limit for the evolution of the trapped particle component. For a smooth transition to the free streaming regime, this 'diffusion source' is limited by the matter emissivity. The resulting streaming particle emission rates are integrated over space to obtain the streaming particle flux. Finally, a geometric estimate of the flux factor is used to convert the particle flux to the streaming particle density, which enters the evaluation of streaming particle-matter interactions. The efficiency of the scheme results from the freedom to use different approximations for each particle component. In supernovae, for example, reactions with trapped particles on fast timescales establish equilibria that reduce the number of primitive variables required to evolve the trapped particle component. On the other hand, a stationary-state approximation considerably facilitates the treatment of the streaming particle component. Different approximations may apply in applications to stellar atmospheres, star formation, or cosmological radiative transfer. We compare the isotropic diffusion source approximation with Boltzmann neutrino transport of electron flavor neutrinos in spherically symmetric supernova models and find good agreement. An extension of the scheme to the multidimensional case is also discussed.
We present SOFIA/FIFI-LS observations of the C ii 158 m cooling line across the nearby spiral galaxy NGC 6946. We combine these with UV, IR, CO, and H i data to compare C ii emission to dust ...properties, star formation rate (SFR), H2, and H i at 560 pc scales via stacking by environment (spiral arms, interarm, and center), radial profiles, and individual, beam-sized measurements. We attribute 73% of the C ii luminosity to arms, and 19% and 8% to the center and interarm region, respectively. C ii/TIR, C ii/CO, and C ii/PAH radial profiles are largely constant, but rise at large radii ( 8 kpc) and drop in the center ("C ii deficit"). This increase at large radii and the observed decline with the 70 m/100 m dust color are likely driven by radiation field hardness. We find a near proportional C ii-SFR scaling relation for beam-sized regions, though the exact scaling depends on methodology. C ii also becomes increasingly luminous relative to CO at low SFR (interarm or large radii), likely indicating more efficient photodissociation of CO and emphasizing the importance of C ii as an H2 and SFR tracer in such regimes. Finally, based on the observed C ii and CO radial profiles and different models, we find CO to increase with radius, in line with the observed metallicity gradient. The low CO (galaxy average 2 M pc−2 (K km s−1)−1) and low C ii/CO ratios (∼400 on average) imply little CO-dark gas across NGC 6946, in contrast to estimates in the Milky Way.
Meningiomas are among the most common primary tumors of the central nervous system (CNS) and originate from the arachnoid or meningothelial cells of the meninges. Surgery is the first option of ...treatment, but depending on the location and invasion patterns, complete removal of the tumor is not always feasible. Reports indicate many differences in meningiomas from male versus female patients; for example, incidence is higher in females, whereas males usually develop the malignant and more aggressive type. With this as motivation, we used shotgun proteomics to compare the proteomic profile of grade I meningioma biopsies of male and female patients. Our results listed several differentially abundant proteins between the two groups; some examples are S100-A4 and proteins involved in RNA splicing events. For males, we identified enriched pathways for cell-matrix organization and for females, pathways related to RNA transporting and processing. We believe our findings contribute to the understanding of the molecular differences between grade I meningiomas of female and male patients.
Plant extracts have been proposed as substitutes for chemical feed additives due to their potential as rumen fermentation modifiers and because of their antimicrobial and antioxidant activities, ...possibly reducing methane emissions. This study aimed to evaluate the use of oregano (OR), green tea extracts (GT), and their association as feed additives on the performance and methane emissions from dairy between 28 and 87 d of lactation. Thirty-two lactating dairy cows, blocked into 2 genetic groups: 16 Holstein cows and 16 crossbred Holstein-Gir, with 522.6 ± 58.3 kg of body weight, 57.2 ± 20.9 d in lactation, producing 27.5 ± 5.0 kg/cow of milk and with 3.1 ± 1.8 lactations were evaluated (means ± standard error of the means). Cows were allocated into 4 treatments: control (CON), without plant extracts in the diet; oregano extract (OR), with the addition of 0.056% of oregano extract in the dry matter (DM) of the diet; green tea (GT), with the addition of 0.028% of green tea extract in the DM of the diet; and mixture, with the addition of 0.056% oregano extract and 0.028% green tea extract in the DM of the diet. The forage-to-concentrate ratio was 60:40. Forage was composed of corn silage (94%) and Tifton hay (6%); concentrate was based on ground corn and soybean meal. Plant extracts were supplied as powder, which was previously added and homogenized into 1 kg of concentrate in natural matter, top-dressed onto the total mixed diet. No treatment by day interaction was observed for any of the evaluated variables, but some block by treatment interactions were significant. In Holstein cows, the mixture treatment decreased gross energy and tended to decrease the total-tract apparent digestibility coefficient for crude protein and total digestible nutrients when compared with OR. During the gas measurement period, GT and OR increased the digestible fraction of the ingested DM and decreased CH4 expressed in grams per kilogram of digestible DMI compared with CON. The use of extracts did not change rumen pH, total volatile fatty acid concentration, milk yield, or most milk traits. Compared with CON, oregano addition decreased fat concentration in milk. The use of plant extracts altered some milk fatty acids but did not change milk fatty acids grouped according to chain length (short or long), saturation (unsaturated or saturated), total conjugated linoleic acids, and n-3 and n-6 contents. Green tea and oregano fed separately reduced gas emission in cows during the first third of lactation and have potential to be used as feed additives for dairy cows.
To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and ...zonisamide) in the treatment of children and adults with refractory partial and generalized epilepsies.
A 23-member committee including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until March 2003.
All of the new AEDs were found to be appropriate for adjunctive treatment of refractory partial seizures in adults. Gabapentin can be effective for the treatment of mixed seizure disorders, and gabapentin, lamotrigine, oxcarbazepine, and topiramate for the treatment of refractory partial seizures in children. Limited evidence suggests that lamotrigine and topiramate are also effective for adjunctive treatment of idiopathic generalized epilepsy in adults and children, as well as treatment of the Lennox Gastaut syndrome.
The choice of AED depends upon seizure and/or syndrome type, patient age, concomitant medications, AED tolerability, safety, and efficacy. The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with refractory epilepsy and identify those seizure types and syndromes where more evidence is necessary.
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