Opioid use disorder (OUD) is a chronic, relapsing condition with severe negative health consequences. Previous studies have reported that 5-year opioid abstinence is a good predictor of reduced ...likelihoods of relapse, but factors that shape long-term opioid abstinence are poorly understood. The present study is based on data from a prospective study of 699 adults with OUD who had been randomized to either methadone or buprenorphine/naloxone and who were followed for at least 5 years. During the 5 years prior to the participants’ last follow-up interview, 232 (33.2%) had achieved 5-year abstinence from heroin. Of those 232, 145 (20.7% of the total) had remained abstinent from both heroin and other opioids (e.g., hydrocodone, oxycodone, other opioid analgesics, excluding methadone or buprenorphine). Compared to non-abstinent individuals, those in both categories of opioid abstinence had lower problem severity in health and social functioning at the final follow-up. Logistic regression results indicated that cocaine users and injection drug users were less likely to achieve 5-year heroin abstinence, whereas Hispanics (vs. whites) and those treated in clinics on the West Coast (vs. East) were less likely to achieve 5-year abstinence from heroin and other opioids. For both abstinence category groups, abstinence was positively associated with older age at first opioid use, lower impulsivity, longer duration of treatment for OUD, and greater social support. Reducing cocaine use and injection drug use and increasing social support and retention in treatment may help maintain long-term abstinence from opioids among individuals treated with agonist pharmacotherapy.
Abstract Objectives Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims ...to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI. Methods A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist. Results A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography. Conclusions A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.
Industrial systems can be complex and not intuitive to perceive. Therefore, students in technology and engineering programs can benefit from developing mental models of industrial systems during ...their journey in college. However, more often than not, these students do not have access to industrial facilities; thus, developing mental models for systems is a challenge. This paper examines the merit of an Immersive Virtual Reality (IVR) framework application in creating proper mental models for industrial systems in technology and engineering students. Two IVR applications were developed. One IVR application afforded interaction with components of a prefabricated industrial cooling water system (CWVR). In the other application, students designed and built industrial systems with IVR (system designer VR SDVR). SDVR facilitated constructive‐generative engagement. A group of 33 students was divided into two; one group (the Design, experimental group) was tasked with building a system with SDVR and interacting with the cooling water system in CWVR. The other group was tasked with directly interacting with the CWVR without building a system with SDVR (the Interaction, comparison group). Students' mental models of the cooling water system in CWVR were evaluated following completing the interaction experience with CWVR. The results demonstrate that the causal model notion of the mental model of the cooling water system was significantly higher in the Design, experimental group. The results suggest that designing a rich IVR application that facilitates constructive‐generative engagements may carry merit in informing student mental models of complex technical concepts.
Lay Description
Industrial systems can be complex and not intuitive to perceive.
Students in technology‐related programs may struggle to develop mental models for systems.
Immersive virtual reality applications for industrial systems were developed and tested.
Results indicate that virtual reality might inform mental models of systems in students.
Recent developments to spatial-capture recapture models have allowed their use on species whose members are not uniquely identifiable from photographs by including individual identity as a latent, ...unobserved variable in the model. These ‘unmarked’ spatial capture recapture (uSCR) models have also been extended to presence-absence data and modified to allow categorical environmental covariates on density, but a uSCR model, which allows fitting continuous environmental covariates to density, has yet to be formulated. In this paper, we fill this gap and present an extension to the uSCR modeling framework by modeling animal density on a discrete state space as a function of continuous environmental covariates and investigate a form of Bayesian variable selection to improve inference. We used an elk population in their winter range within Karuk Indigenous Territory in Northern California as a case study and found a positive credible effect of increasing forb/grass cover on elk density and a negative credible effect of increasing tree cover on elk density. We posit that our extensions to uSCR modeling increase its utility in a wide range of ecological and management applications in which spatial counts of wildlife can be derived and environmental heterogeneity acts as a control on animal density.
This study aimed to estimate the proportion of total hospital discharges that involved a primary or secondary substance-related diagnosis code (SubDx) on inpatient medicine, psychiatry, and surgery ...services as part of a needs assessment for inpatient addiction consultation at our large, academic-affiliated Veterans Affairs (VA) hospital.
We first calculated the percentage of total and service-specific discharges with a primary or secondary substance-related International Classification of Disease, Tenth Revision , code on all inpatient services (medicine, psychiatry, and surgery) in Fiscal Year 2017, 2018, and 2019, using facility-level data. Second, we calculated the proportion of total discharges that involved alcohol- and opioid-related diagnoses.
Over the 3 years studied, 29% of total discharges had a SubDx (4469 of 15,575). The proportion of total discharges that involved a SubDx was 23% (1246 of 5449) in 2017, 31% (1664 of 5332) in 2018, and 33% in 2019 (1559 of 4794), a statistically significant increase ( P < 0.001). As a percentage of service-specific discharges, 65% of discharges from psychiatry (1446 of 2217) had a SubDx, compared with 25% from medicine (2469 of 9713), and 15% from surgery (554 of 3645). Medicine services had the most discharges with SubDx, with a year-over-year increase in the number of discharges with SubDx. The percentage of total discharges that involved alcohol- and opioid-related diagnoses was 14% and 4%, respectively.
Substance-related diagnoses are prevalent at our hospital and are increasing over time. The largest number of discharges with SubDx was found on medicine services. Alcohol-related diagnoses were nearly 4 times more prevalent than opioid-related diagnoses. We found focused need around alcohol use and alcohol withdrawal.
Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need ...for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.
Background
Patients with post‐traumatic stress disorder (PTSD) have complex and multiple symptoms, including anxiety, insomnia, and co‐occurring pain, often treated with opioids and benzodiazepines. ...While concurrent use of these medications poses safety concerns, little is known about the trends of long‐term concurrent use and the prevalence of high‐risk conditions among those who are prescribed them. Study objectives were to examine the trends in annual prevalence of long‐term concurrent opioid and benzodiazepine use among patients with PTSD and prevalence of high‐risk conditions in concurrent users of these medications.
Design
Retrospective review of pharmacy records of the Veteran Affairs Northwest Integrated Network (VISN20).
Subjects
Patients (n = 66,210) with PTSD receiving care during 2003–2011.
Methods
Concurrent use was defined as overlapping opioid and benzodiazepine prescriptions for ≥90 consecutive days. Gender‐specific logistic regressions estimated long‐term concurrent use of these medications and tested for linear trends over 9‐years.
Results
The trend in age‐adjusted long‐term concurrent opioid and benzodiazepine use over 9‐years increased 52.7%, from 3.6% (95% confidence interval, 3.3–3.9%) to 5.5% (5.3–5.8%), in men and 79.5%, from 3.9% (3.0–5.0%) to 7.0% (6.2–7.9%), in women. In 2011, 17.1% of long‐term concurrent users were prescribed morphine‐equivalent daily doses of opioids ≥100 mg and 49.4% had a documented high‐risk condition.
Conclusion
Despite known risks associated with prescribing opioids and benzodiazepines concurrently, the adjusted prevalence of long‐term concurrent use rose significantly among men and women with PTSD in VISN20 over a 9‐year period. Common use of these medications among patients with high‐risk conditions suggests comprehensive strategies are needed to identify and monitor patients at increased risk for adverse outcomes.
Incidental Pancreatic Cystic Lesions Edirimanne, Senarath; Connor, Saxon J.
World journal of surgery,
September 2008, Volume:
32, Issue:
9
Journal Article
Peer reviewed
Introduction
Incidental pancreatic cystic lesions (IPCL) are becoming an increasingly frequent clinical entity. Within this review, the differential diagnosis, investigation, and management are ...discussed.
Methods
A MEDLINE search was performed for IPCL.
Results
Incidence of IPCL varies from 0.2–0.7%, and 30–47% are premalignant or malignant. Pancreatic pseudocysts (PC), serous cystic neoplasms (SCN), intraductal papillary mucinous neoplasms (IPMN), and mucinous cystic neoplasms (MCN) are the most common pathological entities of IPCL. The use of combined modalities, including clinical characteristics, serum tumor markers, cross-sectional imaging, and endoscopic ultrasound (EUS) with cyst fluid analysis should all be used to establish an accurate preoperative diagnosis if possible. Modern multidetector computed tomography (MDCT) and magnetic resonance pancreatography (MRP) allow detailed characterization of IPCL, including size, septation, calcifications, mural nodules, and communication with main pancreatic duct. The best available cyst fluid markers of mucinous neoplasm are viscosity ≥1.6 and carcinoembryonic antigen >192 ng/ml. Although surgery is indicated for MCN or main or mixed duct IPMN, recent advances in the understanding of the natural history and increasingly accurate preoperative diagnosis allow a nonoperative approach to be undertaken for the majority of IPCL. For those treated nonoperatively, the ideal follow-up has yet to be determined.
Conclusions
Emerging evidence supports selective nonoperative management for the majority of patients who have IPCL when investigated by a multimodal approach. For those in whom a suspicion of malignancy remains, surgery is indicated.
Pragmatic primary care trials aim to test interventions in "real world" health care settings, but clinics willing and able to participate in trials may not be representative of typical clinics. This ...analysis compared patients in participating and non-participating clinics from the same health systems at baseline in the PRimary care Opioid Use Disorders treatment (PROUD) trial.
This observational analysis relied on secondary electronic health record and administrative claims data in 5 of 6 health systems in the PROUD trial. The sample included patients 16-90 years at an eligible primary care visit in the 3 years before randomization. Each system contributed 2 randomized PROUD trial clinics and 4 similarly sized non-trial clinics. We summarized patient characteristics in trial and non-trial clinics in the 2 years before randomization ("baseline"). Using mixed-effect regression models, we compared trial and non-trial clinics on a baseline measure of the primary trial outcome (clinic-level patient-years of opioid use disorder (OUD) treatment, scaled per 10,000 primary care patients seen) and a baseline measure of the secondary trial outcome (patient-level days of acute care utilization among patients with OUD).
Patients were generally similar between the 10 trial clinics (n = 248,436) and 20 non-trial clinics (n = 341,130), although trial clinics' patients were slightly younger, more likely to be Hispanic/Latinx, less likely to be white, more likely to have Medicaid/subsidized insurance, and lived in less wealthy neighborhoods. Baseline outcomes did not differ between trial and non-trial clinics: trial clinics had 1.0 more patient-year of OUD treatment per 10,000 patients (95% CI: - 2.9, 5.0) and a 4% higher rate of days of acute care utilization than non-trial clinics (rate ratio: 1.04; 95% CI: 0.76, 1.42).
trial clinics and non-trial clinics were similar regarding most measured patient characteristics, and no differences were observed in baseline measures of trial primary and secondary outcomes. These findings suggest trial clinics were representative of comparably sized clinics within the same health systems. Although results do not reflect generalizability more broadly, this study illustrates an approach to assess representativeness of clinics in future pragmatic primary care trials.
PDF
