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Introduction: Opioid side effects are common when treating chronic pain. However, the rate of opioid side effects for acute pain has rarely been examined, particularly in the post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid induced side effects (constipation, nausea/vomiting, dizziness, and drowsiness) in patients discharged from the ED with an opioid prescription. Methods: This was a prospective cohort study of patients aged ≥18 years that visited the ED for an acute pain condition (≤ 2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects. Results: Mean age of the 386 patients included was 55 ± 16 years; 50% were women. During the 2-week follow-up, 80% of patients consumed at least one dose of opioids. Among the patients who used opioids, 38% (95%CI: 33-48) reported constipation, 27% (95%CI:22-32) nausea/vomiting, 30% (95%CI:25-35) dizziness, 51% (95%CI:45-57) drowsiness, and 77% (95%CI:72-82) reported any side effects. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report any side effect (OR 7.5, 95%CI:4.3-13.3) and constipation (OR 7.5, 95%CI:3.1-17.9). A significant dose response effect was observed for constipation but not for the other side effects. Nausea/vomiting (OR 2.0, 95%CI:1.1-3.6) and dizziness (OR 1.9, 95%CI:1.1-3.4) were associated with oxycodone compared to morphine. Conclusion: Similar to chronic pain, opioid side effects are highly prevalent during short-term treatment for acute pain. Physicians should be aware and inform patients about those side effects.
Characterising the three-dimensional (3D) distribution of hydraulic conductivity and its variability in the shallow subsurface is fundamental to understanding groundwater behaviour and to developing conceptual and numerical groundwater models to manage the subsurface. However, directly measuring in situ hydraulic conductivity can be difficult and expensive and is rarely carried out with sufficient density in urban environments. In this study we model hydraulic conductivity for 603 sites in the unconsolidated Quaternary deposits underlying Glasgow using particle size distribution and density description widely available from geotechnical investigations. Six different models were applied and the MacDonald formula was found to be most applicable in this heterogeneous environment, comparing well with the few available in situ hydraulic conductivity data. The range of the calculated hydraulic conductivity values between the 5th and 95th percentile was 1.56×10–2–4.38mday–1 with a median of 2.26×10–1 mday–1. These modelled hydraulic conductivity data were used to develop a suite of stochastic 3D simulations conditioned to existing 3D representations of lithology. Ten per cent of the input data were excluded from the modelling process for use in a split-sample validation test, which demonstrated the effectiveness of this approach compared with non-spatial or lithologically unconstrained models. Our spatial model reduces the mean squared error between the estimated and observed values at the excluded data locations over those predicted using a simple homogeneous model by 73 %. The resulting 3D hydraulic conductivity model is of a much higher resolution than would have been possible from using only direct measurements, and will improve understanding of groundwater flow in Glasgow and reduce the spatial uncertainty of hydraulic parameters in groundwater process models. The methodology employed could be replicated in other regions where significant volumes of suitable geotechnical and site investigation data are available to predict ground conditions in areas with complex superficial deposits.
Across the British empire, public worship was important for sustaining a sense of community and connectedness. This was most evident in special acts of worship, when the peoples of imperial territories, and sometimes of the whole empire, were asked at times of crisis and celebration to join together in special days or prayers of petition or thanksgiving to God. These occasions, ordered by a variety of civil and ecclesiastical authorities, were an enduring feature of all colonial societies from the seventeenth to the mid-twentieth centuries. Although these special acts of worship have considerable potential for deepening our understanding of various themes in the history of the British empire, they have yet to receive sustained analysis from scholars. This article is concerned with the fundamental task of considering why and how special prayers and days of fasting, humiliation, intercession and thanksgiving were appointed across the empire. By focusing on the causes of, and orders for, these occasions, it indicates reasons for the longevity of this practice, as well as its varied and changing purposes.
Introduction: Gastroenteritis accounts for 1.7 million emergency department visits by children annually in the United States. We conducted a double-blind trial to determine whether twice daily probiotic administration for 5 days, improves outcomes. Methods: 886 children aged 348 months with gastroenteritis were enrolled in six Canadian pediatric emergency departments. Participants were randomly assigned to twice daily Lactobacillus rhamnosus R0011 and Lactobacillus helveticus R0052, 4.0 x 109 CFU, in a 95:5 ratio or placebo. Primary outcome was development of moderate-severe disease within 14 days of randomization defined by a Modified Vesikari Scale score 9. Secondary outcomes included duration of diarrhea and vomiting, subsequent physician visits and adverse events. Results: Moderate-severe disease occurred in 108 (26.1%) participants administered probiotics and 102 (24.7%) participants allocated to placebo (OR 1.06; 95%CI: 0.77, 1.46; P=0.72). After adjustment for site, age, and frequency of vomiting and diarrhea, treatment assignment did not predict moderate-severe disease (OR, 1.11, 95%CI, 0.80 to 1.56; P=0.53). In the probiotic versus placebo groups, there were no differences in the median duration of diarrhea [52.5 (18.3, 95.8) vs. 55.5 (20.2, 102.3) hours; P=0.31], vomiting [17.7 (0, 58.6) vs. 18.7 (0, 51.6) hours; P=0.18], physician visits (30.2% vs. 26.6%; OR 1.19; 95% CI0.87. 1.62; P=0.27), or adverse events (32.9% vs. 36.8%; OR 0.83; 95%CI 0.62. 1.11; P=0.21). Conclusion: In children presenting to an emergency department with gastroenteritis, twice daily administration of 4.0 x 109 CFU of a Lactobacillus rhamnosus/helveticus probiotic does not prevent development of moderate-severe disease or improvements in other outcomes measured.
Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.
Introduction: Undertreated pain is known to cause short and long-term harm in children. Limb injuries are a common painful condition in emergency department (ED) patients, accounting for 12% of ED visits by children. Our city has one pediatric ED in a freestanding children’s hospital and 3 general ED’s that treat both adults and children. 68% of pediatric limb injuries in our city are treated in the pediatric ED and 32% are treated in a general ED. A quality improvement (QI) initiative was developed at the children’s hospital ED in April 2015 focusing on “Commitment to Comfort.” After achieving aims at the childrens hospital, a QI collaborative was formed among the pediatric ED and the 3 general ED’s to 1) improve the proportion of children citywide receiving analgesia for limb injuries from 27% to 40% and 2) reduce the median time to analgesia from 37 minutes to 15 minutes, during the time period of April-September, 2016. Methods: Data were obtained from computerized order entry records for children 0-17.99 years visiting any participating ED with a chief complaint of limb injury. Project teams from each site met monthly to discuss aims, develop key driver diagrams, plan tests of change, and share learnings. Implementation strategies were based on the Model for Improvement with PDSA cycles. Patient and family consultation was obtained. Process measures included the proportion of children treated with analgesic medication and time to analgesia; balancing measures were duration of triage and length of stay for limb injury and all patients. Site-specific run charts were used to detect special cause variation. Data from all sites were combined at study end to measure city-wide impact using 2 and interrupted time series analysis. Results: During the 3.5-year time period studied (April 1, 2014-September 30, 2017), there were 45,567 visits to the participating ED’s by children 0-17.99 years with limb injury. All visits were included in analysis. Special cause was detected in run charts of all process measures. Interrupted time series analysis comparing the year prior to implementation at the childrens hospital in April 2015 to the year following completion of implementation at the 3 general hospitals in October 2016 demonstrated that the proportion of patients with limb injury receiving analgesia increased from 27% to 40% (p<0.01), and the median time from arrival to analgesia decreased from 37 to 11 minutes (p<0.01). Balancing measure analysis is in progress. Conclusion: This multisite initiative emphasizing “Commitment to Comfort” was successful in improving pain outcomes for all children with limb injuries seen in city-wide ED’s, and was sustained for one year following implementation. A QI collaborative can be an effective method for spreading improvement. The project team is now spreading the Commitment to Comfort initiative to over 30 rural and regional EDs throughout the province through establishment of a provincial QI collaborative.
Introduction: In high-income countries, vomiting often impedes oral rehydration therapy, leading to intravenous rehydration fluid administration to children with acute gastroenteritis. Ondansetron administration reduces vomiting and intravenous fluid administration in this population. We evaluated whether ondansetron is similarly effective when employed in Pakistan. Methods: In this 2-hospital, double-blind, placebo-controlled, emergency department-based, randomized trial, we recruited children aged 0·5 to 5·0 years, without dehydration, who had diarrhea and 1 episode of vomiting within 4 hours of arrival. Patients were randomly assigned (1:1), via an internet-based randomization service, using a stratified, variable block randomization scheme, to receive a single dose of oral ondansetron or placebo. The primary endpoint was intravenous rehydration (administration of 20 ml/kg over 4 hours of an isotonic fluid) within 72 hours of randomization. All randomized children were analysed. Results: From July 3, 2014, to January 12, 2017, 626 children were randomized. Intravenous rehydration was provided to 10.8% (34/314) and 10.3% (27/312) of children administered placebo and ondansetron, respectively (OR: 0.946; 95% CI: 0.564, 1.587; P=0.834). A regression model fitted with treatment group and adjusted for antiemetic administration and vomiting frequency in the preceding 24 hours, yielded similar results; OR=0.952; 95% CI: 0.570, 1.589; P=0.850. There was no evidence of interaction between treatment group and age (P=0.974), 3 diarrheal stools in the preceding 24 hours (P=0.983) or 3 vomits in the preceding 24 hours (P=0.554). During the 4-hour study observation period, 24.0% (75/314) and 19.6% (61/312) of children in the placebo and ondansetron groups vomited, respectively; OR: 0.774; 95%CI: 0.528, 1.133; P=0.187. Conclusion: Ondansetron administration did not significantly reduce intravenous rehydration use, suggesting that in children without dehydration, ondansetron administration does not significantly alter the disease course and should not be administered to this group of children.
We develop a framework for understanding how legal structures relate to imprisonment. We hypothesize that relatively more hierarchy within criminal justice institutions, compared to commercial law, fosters higher rates of incarceration. Our framework predicts that incarceration reflects asymmetric opportunities for rent seeking across differently organized legal institutions. Instead of comparing criminal justice institutions across nations in absolute terms, we investigate the relative degrees of institutional centralization across legal spheres. To provide support, we document the separate historical experiences that shaped divergent organizations across England and France. Within each country, criminal legal institutions developed inverse organizational traits from commercial legal processes. As a result, the contrasting organizations created asymmetric opportunities for rent seeking. Divergent contemporary outcomes can be understood by recognizing these initial organizational choices, the relative opportunities they created, and their subsequent path dependencies. We document contemporary England, France, and the United States’ incarceration trends and penal outcomes to provide empirical support.
We examined norovirus contamination on hands of ill patients during 12 norovirus outbreaks in 12 long-term care facilities (LTCFs). The higher frequency and norovirus titers on hands of residents compared to hands of heathcare workers highlights the importance of adhering to appropriate hand hygiene practices during norovirus outbreaks in LTCFs.
Examining neurometabolic abnormalities in critical brain areas in schizophrenia and major depressive disorder (MDD) may help guide future pharmacological interventions including glutamate-modulating treatments.
To measure metabolite concentrations within the anterior cingulate cortex (ACC) and thalamus of people with schizophrenia and people with MDD.
Spectra were acquired from 16 volunteers with schizophrenia, 17 with MDD and 18 healthy controls using magnetic resonance spectroscopy on a 7 Tesla scanner.
In the thalamus, there were lower glycine concentrations in the schizophrenia group relative to control (P=0.017) and MDD groups (P=0.012), and higher glutamine concentrations relative to healthy controls (P=0.009). In the thalamus and the ACC, the MDD group had lower myo-inositol concentrations than the control (P=0.014, P=0.009, respectively) and schizophrenia (P=0.004, P=0.002, respectively) groups.
These results support the glutamatergic theory of schizophrenia and indicate a potential glycine deficiency in the thalamus. In addition, reduced myo-inositol concentrations in MDD suggest its involvement in the disorder.
Acute rheumatic fever (ARF) continues to produce a significant burden of disease in New Zealand (NZ) Māori and Pacific peoples. Serious limitations in national surveillance data mean that accurate case totals cannot be generated. Given the changing epidemiology of ARF in NZ and the major national rheumatic fever prevention programme (2012–2017), we updated our previous likely true case number estimates using capture–recapture analyses. Aims were to estimate the likely true incidence of ARF in NZ and comment on the changing ability to detect cases. Data were obtained from national hospitalisation and notification databases. The Chapman Estimate partially adjusted for bias. An estimated 2342 likely true new cases arose from 1997 to 2015, giving a mean annual incidence of 2·9 per 100 000 (95% CI 2·5–3·5). Compared with the pre-intervention (2009–2011) baseline incidence (3·4 per 100 000, 95% CI 2·9–4·0), the likely true 2015 incidence declined 44%. Large gaps in data completeness are slowly closing. During the period 2012–2015, 723 cases were identified; 83·8% of notifications were matched to hospitalisation data, and 87·2% of hospitalisations matched to notifications. Despite this improvement, clinicians need to remain aware of the need to notify atypical patients. A possible unintended consequence of the national ARF prevention programme is increased misdiagnosis.
An updated compilation of published and new data of major-ion (Ca, Cl, K, Mg, Na, NO3, SO4) and methylsulfonate (MS) concentrations in snow from 520 Antarctic sites is provided by the national ITASE (International Trans-Antarctic Scientific Expedition) programmes of Australia, Brazil, China, Germany, Italy, Japan, Korea, New Zealand, Norway, the United Kingdom, the United States and the national Antarctic programme of Finland. The comparison shows that snow chemistry concentrations vary by up to four orders of magnitude across Antarctica and exhibit distinct geographical patterns. The Antarctic-wide comparison of glaciochemical records provides a unique opportunity to improve our understanding of the fundamental factors that ultimately control the chemistry of snow or ice samples. This paper aims to initiate data compilation and administration in order to provide a framework for facilitation of Antarctic-wide snow chemistry discussions across all ITASE nations and other contributing groups. The data are made available through the ITASE web page (http://www2.umaine.edu/itase/content/syngroups/snowchem.html) and will be updated with new data as they are provided. In addition, recommendations for future research efforts are summarized.
In this paper, we are interested in perturbed vortices under the influence of a wall or ground plane. Such flows have relevance to aircraft wakes in ground effect, to ship hull junction flows, to fundamental studies of turbulent structures close to a ground plane and to vortex generator flows, among others. In particular, we study the vortex dynamics of a descending vortex pair, which is unstable to a long-wave instability (Crow, AIAA J., vol. 8 (12), 1970, pp. 2172–2179), as it interacts with a horizontal ground plane. Flow separation on the wall generates opposite-sign secondary vortices which in turn induce the ‘rebound’ effect, whereby the primary vortices rise up away from the wall. Even small perturbations in the vortices can cause significant topological changes in the flow, ultimately generating an array of vortex rings which rise up from the wall in a three-dimensional ‘rebound’ effect. The resulting vortex dynamics is almost unrecognizable when compared with the classical Crow instability. If the vortices are generated below a critical height over a horizontal ground plane, the long-wave instability is inhibited by the wall. We then observe two modes of vortex–wall interaction. For small initial heights, the primary vortices are close together, enabling the secondary vortices to interact with each other, forming vertically oriented vortex rings in what we call a ‘vertical rings mode’. In the ‘horizontal rings mode’, for larger initial heights, the Crow instability develops further before wall interaction; the peak locations are farther apart and the troughs closer together upon reaching the wall. The proximity of the troughs to each other and the wall increases vorticity cancellation, leading to a strong axial pressure gradient and axial flow. Ultimately, we find a series of small horizontal vortex rings which ‘rebound’ from the wall. Both modes comprise two small vortex rings in each instability wavelength, distinct from Crow instability vortex rings, only one of which is formed per wavelength. The phenomena observed here are not limited to the above perturbed vortex pairs. For example, remarkably similar phenomena are found where vortex rings impinge obliquely with a wall.
Ross River virus (RRV) is a mosquito-borne virus endemic to Australia. The disease, marked by arthritis, myalgia and rash, has a complex epidemiology involving several mosquito species and wildlife reservoirs. Outbreak years coincide with climatic conditions conducive to mosquito population growth. We developed regression models for human RRV notifications in the Mildura Local Government Area, Victoria, Australia with the objective of increasing understanding of the relationships in this complex system, providing trigger points for intervention and developing a forecast model. Surveillance, climatic, environmental and entomological data for the period July 2000–June 2011 were used for model training then forecasts were validated for July 2011–June 2015. Rainfall and vapour pressure were the key factors for forecasting RRV notifications. Validation of models showed they predicted RRV counts with an accuracy of 81%. Two major RRV mosquito vectors (Culex annulirostris and Aedes camptorhynchus) were important in the final estimation model at proximal lags. The findings of this analysis advance understanding of the drivers of RRV in temperate climatic zones and the models will inform public health agencies of periods of increased risk.
The structure of a series of lanthanide iron cobalt perovskite oxides, R(Fe0.5Co0.5)O3 (R = Pr, Nd, Sm, Eu, and Gd), have been investigated. The space group of these compounds was confirmed to be orthorhombic Pnma (No. 62), Z = 4. From Pr to Gd, the lattice parameter a varies from 5.466 35(13) Å to 5.507 10(13) Å, b from 7.7018(2) to 7.561 75(13) Å, c from 5.443 38(10) to 5.292 00(8) Å, and unit-cell volume V from 229.170(9) Å3 to 220.376(9) Å3, respectively. While the trend of V follows the trend of the lanthanide contraction, the lattice parameter “a” increases as the ionic radius r(R3+) decreases. X-ray diffraction (XRD) and transmission electron microscopy confirm that Fe and Co are disordered over the octahedral sites. The structure distortion of these compounds is evidenced in the tilt angles θ, ϕ, and ω, which represent rotations of an octahedron about the pseudocubic perovskite p, p, and p axes. All three tilt angles increase across the lanthanide series (for R = Pr to R = Gd: θ increases from 12.3° to 15.2°, ϕ from 7.5° to 15.8°, and ω from 14.4° to 21.7°), indicating a greater octahedral distortion as r(R3+) decreases. The bond valence sum for the sixfold (Fe/Co) site and the eightfold R site of R(Fe0.5Co0.5)O3 reveal no significant bond strain. Density Functional Theory calculations for Pr(Fe0.5Co0.5)O3 support the disorder of Fe and Co and suggest that this compound to be a narrow band gap semiconductor. XRD patterns of the R(Fe0.5Co0.5)O3 samples were submitted to the Powder Diffraction File.