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Introduction: Increasing opioid prescribing has been linked to an epidemic of opioid misuse. Our objective was to synthesize available evidence about patient-, prescriber-, medication-, and system-level risk factors for developing opioid misuse from prescribed opioids among patients presenting with pain unrelated to cancer. Our hypothesis was that we would identify risk factors predisposing patients to developing opioid misuse. Methods: We developed a systematic search strategy and applied it to nine electronic reference databases and six clinical trial registries. We hand searched related journals and conference proceedings, the reference lists of included studies, and the top 100 hits on Google. We included studies where a medical professional exposed adults or children to an opioid through a prescription. We excluded studies with over 50% cancer patients, palliative patients, and those with illicit opioid initiation. Two reviewers independently reviewed titles, abstracts, and full texts, and extracted data using standardized forms. We assessed study quality using risk of bias. We synthesized effect sizes of dichotomous risk factors on opioid misuse using inverse variance random-effects meta-analysis, and the inverse variance-weighted mean difference between opioid misusers and non-misusers for continuously measured factors. We conducted an a priori defined subgroup analysis among opioid-naïve patients. Results: Among 9,629 studies, 67 met our inclusion criteria. Among those who had been prescribed outpatient opioids, the following factors were associated with the development of misuse: a prior history of illicit drug use (OR: 4.21, 95% CI: 2.31-7.65), recent benzodiazepine use (OR: 2.57, 95% CI: 1.23-5.38), any mental health diagnosis (OR: 2.45, 95% CI: 1.91-3.15), any short acting (IR) opioid prescription (OR: 2.40, 95% CI: 1.15-5.02), younger age (OR: 2.19, 95%CI: 1.81-2.64), and male sex (OR: 1.23, 95% CI: 1.10-1.36). Among studies limiting their population to opioid-naïve patients, younger age was the most significant risk factor for opioid misuse (OR: 5.42, 95% CI:1.51-19.43). Conclusion: Of the risk factors examined, non-cancer pain patients with a prior history of substance use or mental health diagnoses were at highest risk for prescription opioid misuse. Younger opioid-naïve patients were at highest risk of misuse. Clinicians should consider these risk factors when managing acute pain in the emergency department.
Toughness is a determinant of meat quality, a common cause of unacceptability in meat products and consumers are willing to pay higher prices for meat which is guaranteed to be tender. The calpain proteolytic enzymes are involved in the process of meat tenderisation through their degradation of muscle proteins postmortem (Sensky et al., 2001) and their activity is influenced by fluctuating levels of Ca2+, pH and temperature, all of which change rapidly in the immediate postmortem period. As vitamin D (vit D3) is responsible for Ca2+ homeostasis, we hypothesised that supplementing feed with vitamin D or vitamin D plus calcium propionate (CaPr) before slaughter would result in more tender meat through enhanced postmortem calpain system activity.
Current models of class II methanol masers are able to describe the brightnesses of the strongest masers and provide a basis for explaining observed line ratios. Determination of the physical parameters in the source requires observational data in many maser transitions. In order to provide observational constraints for models we searched for and detected 7 new methanol masers. This allowed us to constrain the physical parameters of the 3 sources with the greatest number of detected methanol maser lines: W3(OH), NGC6334F, and G345.01 + 1.79. The models accurately account for the fluxes of the bulk of the detected maser lines. Remaining discrepancies most probably reflect the fact that the most prominent components of the different maser lines are formed under different conditions. This is supported by comparison of the line profiles. We outline directions for future studies in the field.
Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million annual emergency department (ED) visits in Canada. Australian data indicate that 27% of ADEs requiring admission are events caused by re-exposure to drugs that previously caused harm. Our objective was to estimate the frequency of repeat ADEs. Methods: We reviewed the charts of ADE patients who had been enrolled in 1 of 3 prospective studies conducted in 2 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal association between the drug regimens and patient presentations. After completion of the parent studies, a research pharmacist and a physician independently reviewed the charts of ADE patients, abstracted data using electronic forms, and searched that hospital’s records for previously recorded ADEs. The main outcome was a repeat ADE, defined as a same or same-class drug re-exposure, or repeat inappropriate drug withdrawal, causing a same or similar presentation as a prior ADE. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 614 ED patients diagnosed with 655 ADEs. Of these, 20% (133/665, 95%CI 17.0-23.0%) were repeat events. Most repeat ADEs were moderate (61%) or severe (32%) in nature, and 33% (95%CI 25.1-41.1%) required hospital admission. The most commonly implicated drugs were warfarin (10%), hydrochlorothiazide (4%) and insulin (4%), and the most commonly implicated drug classes were antithrombotics (17%), psychotropics (12%) and analgesics (9%). Repeat ADEs commonly required clinical monitoring (59%), additional medications to treat the ADE (50%) and follow-up lab testing (35%). Overall, 61% (95%CI 51.3-70.7%) of culprit drug re-exposures were deemed potentially or definitely inappropriate. Conclusion: Inappropriate re-exposures to previously harmful medications cause a substantial number of recurrent ADEs, and may represent an ideal target for prevention. We were unable to search for repeat ADEs in the records of other hospitals that our patients may have visited, and could not detect ADEs that were not documented in the medical record. As a result, we likely underestimated the frequency of repeat ADEs.
Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.
Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, commonly cause or contribute to emergency department (ED) presentations. Understanding provider, patient and system factors that contribute to their development may assist in developing effective preventative strategies. Our objective was to identify factors that contributed to the development of ADEs that caused ED presentations. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal associations between the drug regimens and patient presentations. Subsequently, a research pharmacist and physician independently reviewed the charts of ADE patients from these cohorts, abstracting data using electronic forms. Reviewers recorded patient, provider and system factors that contributed to the development of ADEs. The main outcome was the presence of at least one contributing factor in the development of an ADE. We used descriptive statistics with appropriate measures of variance. The sample size was determined by enrolment into the primary studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We identified ≥1 contributing factors in 62% (95%CI 58-65%) of ADEs. Multiple contributing factors were present in 17% of ADEs (95%CI 13-20%). The most common contributing factors were inadequate patient counseling or instructions about medication use (15%), insufficient laboratory monitoring or follow-up of monitoring tests (12%), lack of staff education (7%), lack of provider adherence with recommended treatment guidelines (7%), and delayed or inadequate clinical reassessment after a medication change (6%). Provider errors in drug administration contributed to 0.3% of ADEs (95%CI 0.0-0.7). Conclusion: Contributing factors were identified for most ADEs. They were often related to inadequate counseling and follow-up, and were rarely the result of errors. Further research is required to understand how communication of medication instructions can be improved. Investments in technologies to reduce provider errors may not significantly reduce the numbers of ADE patients presenting to EDs.
We have used the Australia Telescope Compact Array to search for a number of centimetre wavelength methanol transitions which are predicted to show weak maser emission towards star formation regions. Sensitive, high spatial, and spectral resolution observations towards four high-mass star formation regions which show emission in a large number of class II methanol maser transitions did not result in any detections. From these observations, we are able to place an upper limit of ≲ 1300 K on the brightness temperature of any emission from the 31A+–31A−, 17−2–18−3 E (vt = 1), 124–133 A−, 124–133 A+, and 41A+–41A− transitions of methanol in these sources on angular scales of 2 arcsec. This upper limit is consistent with current models for class II methanol masers in high-mass star formation regions and better constraints than those provided here will likely require observations with next-generation radio telescopes.
Background: Amyotrophic lateral sclerosis (ALS) is a fatal degenerative neurological disease with significant effects on quality of life. International studies continue to provide consistent incidence values, though complete case ascertainment remains a challenge. The Canadian population has been understudied, and there are currently no quantitative data on the incidence of ALS in British Columbia (BC). The objectives of this study were to determine the five-year incidence rates of ALS in BC and to characterize the demographic patterns of the disease. Methods: The capture–recapture method was employed to estimate ALS incidence over a five-year period (2010-2015). Two sources were used to identify ALS cases: one database from an ALS medical centre and another from a not-for-profit ALS organization. Results: During this time period, there were 690 incident cases within the two sources. The capture–recapture method estimated 57 unobserved cases, corresponding to a crude five-year incidence rate of 3.29 cases per 100,000 (CI95%=3.05-3.53). The mean age of diagnosis was 64.6 (CI95%=59.7-69.4), with 63.5 (CI95%=56.9-70.1) for men and 65.7 (CI95%=58.6-72.7) for women. There was a slight male preponderance in incidence, with a 1.05:1 ratio to females. Peak numbers in incidence occurred between the ages of 70 and 79. Conclusions: The incidence of ALS in BC was found to be consistent with international findings though nominally higher than that in other Canadian provinces to date.
The introduction of the Manila clam into British coastal waters in the 1980s was contested by conservation agencies. While recognizing the value of the clam for aquaculture, the government decided that it posed no invasive risk, as British sea temperatures would prevent naturalization. This proved incorrect. Here we establish the pattern of introduction and spread of the species over the first 30 years of its presence in Britain. We report archival research on the sequence of licensed introductions and examine their relationship in time and space to the appearance of wild populations as revealed in the literature and by field surveys. By 2010 the species had naturalized in at least 11 estuaries in southern England. These included estuaries with no history of licensed introduction. In these cases activities such as storage of catch before market or deliberate unlicensed introduction represent the probable mechanisms of dispersal. In any event naturalization is not an inevitable consequence of introduction and the chances of establishment over the period in question were finely balanced. Consequently in Britain the species is not currently aggressively invasive and appears not to present significant risk to indigenous diversity or ecosystem function. However it is likely to gradually continue its spread should sea surface temperatures rise as predicted.
A study is made of the propagation of elastic and plastic deformation in a thin plate, initially unstressed, and of infinite extent, when it is penetrated normally by a cone moving with uniform velocity. The work is an extension of unpublished researches by Sir G. I. Taylor on the corresponding problem for a thin wire, and a summary of his results is included.
The effect of increased levels of suspended sediment on fertilization success in the scleractinian coral Pectinia lactuca was investigated in a laboratory experiment following a mass coral spawning event on reefs off Singapore. Egg–sperm bundles were collected from tank-spawned coral colonies collected from the field several days prior to the anticipated mass spawning. Eggs and sperm from each colony were separated and distributed systematically across replicated treatments (N = 9) with three concentrations of fine suspended sediment. Spawning and embryo development in Pectinia lactuca followed a pattern similar to other scleractinian coral species. There was a significant effect of increased suspended sediment concentration on fertilization success (P < 0.05). Both high- (169 mg l−1) and medium- (43 mg l−1) suspended sediment treatments decreased fertilization success compared to controls. These results imply that increased turbidity levels (whether chronic, such as in the waters around Singapore, or short-term, caused by a dredging operation)—when coinciding with the coral spawning season—may affect the reproductive success of corals and compromise coral recruitment and recovery of degraded reefs.
Central to the United Nations Framework setting out the human rights responsibilities of corporations proposed by John Ruggie is the principle that corporations have a responsibility to respect human rights in their operations whether or not doing so is required by law and whether or not human rights laws are actively enforced. Ruggie proposes that corporations should respect this principle in their strategic management and day-to-day operations for reasons of corporate (enlightened) self-interest. This paper identifies this as a serious weakness and argues that identifying the responsibility to respect human rights as an explicitly ethical obligation to be respected for that reason would provide a much stronger justificatory foundation for respecting the principle seen from a corporate perspective, given that corporations are accountable to their shareholders for their deployment of the firm’s financial resources.
Transport is an essential part of any society. Transport systems support economic growth and meet expectations for travel and communication in an increasingly mobile society. Despite its importance, investment in transport infrastructure was limited during the twentieth century – a situation aggravated by unprecedented growth in private car use throughout the UK and elsewhere. The last UK Conservative government introduced a range of measures that altered the balance between subsidised public services and market-driven private services. Competition became a key driver in government policy and the deregulation of bus services transformed the lynchpin of the public transport system.
There has also been an increasing awareness of the environmental costs of travel and the need to address environmental impacts of travel and transport systems. The damaging effects of road congestion on economic activity and growth and of vehicle emissions on climate change were being increasingly recognised at the same time as vehicle use became increasingly essential to people's everyday lives.
These were the transport issues and challenges facing the new Scottish Parliament – challenges which had to be addressed in the context of national and local government structures, the legal framework for transport and the environment, and the availability of funding to support investment. In dealing with these challenges, the Scottish Parliament has taken into account the key drivers of infrastructure investment, environmental mitigation and social inclusion.
In Ethics and the Limits of Philosophy, Bernard Williams offers an unsettling critique of modern moral philosophy, a critique that calls for a radical reorientation that would have us start again leaving behind much or most or what has been done from the time of the flowering of classical philosophy. However, like moral philosophy itself, Williams' critique reaches beyond the theoretical to matters of practical concern. Moral philosophy since the time of Socrates has endeavoured to answer the question, “How should one live?” (1). Williams' critique is unsettling not simply or primarily because it implies that philosophy has much less to contribute to answering this question than Socrates and most philosophers since his time have thought. Rather, it is unsettling because it implies that Socrates' view that an unexamined life is not worth living, together with his assumption, shared by most moral philosophers since his time, that determining how one should live requires that one step back and reflect on the values governing one's life (19ff.), is either seriously misleading (110 and 116) or mistaken (168).
One of the striking characteristics of contemporary moral philosophy is the speed with which philosophers in the English-speaking world have jettisoned their reluctance to address concrete ethical problems and dilemmas and have plunged into the field of applied ethics. No less interesting is the impact that the work of some of the more noted of them has had outside of strictly philosophical circles. One need only to mention John Rawls or H. L. A. Hart to make the point. It is no longer difficult to prove that these same trends are deeply entrenched amongst Canadian philosophers. A further parallel is suggested by the fact that a Canadian philosopher, George Grant, has also had a substantial impact on recent Canadian thought. The appearance of a parallel, however, is illusory. For while applied ethics certainly has its practitioners in Canada today, and while it is widely recognized that both American and British philosophers have had a substantial and philosophically respectable impact on their respective societies, there seems widespread resistance to the idea that philosophical reflection has a role to play in the development of a distinctive understanding of Canadian society. And there is widespread scepticism in professional philosophical circles in Canada that the work of George Grant is of genuine philosophical interest, whatever his popular reputation.