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Opioid use disorder is a major public health crisis, and evidence suggests ways of better serving patients who live with opioid use disorder in the emergency department (ED). A multi-disciplinary team developed a quality improvement project to implement this evidence.
The intervention was developed by an expert working group consisting of specialists and stakeholders. The group set goals of increasing prescribing of buprenorphine/naloxone and providing next day walk-in referrals to opioid use disorder treatment clinics. From May to September 2018, three Alberta ED sites and three opioid use disorder treatment clinics worked together to trial the intervention. We used administrative data to track the number of ED visits where patients were given buprenorphine/naloxone. Monthly ED prescribing rates before and after the intervention were considered and compared with eight nonintervention sites. We considered whether patients continued to fill opioid agonist treatment prescriptions at 30, 60, and 90 days after their index ED visit to measure continuity in treatment.
The intervention sites increased their prescribing of buprenorphine/naloxone during the intervention period and prescribed more buprenorphine/naloxone than the controls. Thirty-five of 47 patients (74.4%) discharged from the ED with buprenorphine/naloxone continued to fill opioid agonist treatment prescriptions 30 days and 60 days after their index ED visit. Thirty-four patients (72.3%) filled prescriptions at 90 days.
Emergency clinicians can effectively initiate patients on buprenorphine/naloxone when supports for this standardized evidence-based care are in place within their practice setting and timely follow-up in community is available.
Economic hardship (EH) may link to poorer child diet, however whether this association is due to resource limitations or effects on family functioning is unknown. This study examines whether parenting stress mediates the association between EH and child consumption of foods high in saturated fats and added sugars (SFAS).
Data were collected from the Fragile Families and Child Wellbeing study. EH was assessed using eight items collected when children were between 1–9 years old. Mothers reported parenting stress and frequency of child consumption of high SFAS foods when children were 9 years old. Latent growth curve modelling (LGCM) and structural equation modelling tested direct associations between the starting level/rate of change in EH and high SFAS food consumption, and parenting stress as a mediator of the association.
Twenty US cities.
Mothers/children (n 3846) followed birth through age 9 years, oversampled ‘high-risk’, unmarried mothers.
LGCM indicated a curvilinear trend in EH from ages 1–9, with steeper increases from ages 3–9 years. EH did not directly predict the frequency of high SFAS foods. Average EH at 3 and 5 years and change in EH from ages 1–9 predicted higher parenting stress, which in turn predicted more frequent consumption of high SFAS foods.
Findings suggest it may be important to consider parenting stress in early prevention efforts given potential lasting effects of early life EH on child consumption of high SFAS foods. Future research should explore how supports and resources may buffer effects of EH-related stress on parents and children.
In recent years, there has been increased use of dicamba due to the introduction of dicamba-resistant cotton and soybean in the United States. Therefore, there is a potential increase in off-target movement of dicamba and injury to sensitive crops. Flue-cured tobacco is extremely sensitive to auxin herbicides, particularly dicamba. In addition to yield loss, residue from drift or equipment contamination can have severe repercussions for the marketability of the crop. Studies were conducted in 2016, 2017, and 2018 in North Carolina to evaluate spray-tank cleanout efficiency of dicamba using various cleaning procedures. No difference in dicamba recovery was observed regardless of dicamba formulation and cleaning agent. Dicamba residue decreased with the number of rinses. There was no difference in dicamba residue recovered from the third rinse compared with residue from the tank after being refilled for subsequent tank use. Recovery ranged from 2% to 19% of the original concentration rate among the three rinses. Field studies were also conducted in 2018 to evaluate flue-cured tobacco response to reduced rates of dicamba ranging, from 1/5 to 1/10,000 of a labeled rate. Injury and yield reductions varied by environment and application timing. When exposed to 1/500 of a labeled rate at 7 and 11 wk after transplanting, tobacco injury ranged from 39% to 53% and 10% to 16% 24 days after application, respectively. The maximum yield reduction was 62%, with a 55% reduction in value when exposed to 112 g ha−1 of dicamba. Correlations showed significant relationships between crop injury assessment and yield and value reductions, with Pearson values ranging from 0.24 to 0.63. These data can provide guidance to growers and stakeholders and emphasize the need for diligent stewardship when using dicamba technology.
Currently, there are seven herbicides labeled for U.S. tobacco production; however, additional modes of action are greatly needed in order to reduce the risk of herbicide resistance. Field experiments were conducted at five locations during the 2017 and 2018 growing seasons to evaluate flue-cured tobacco tolerance to S-metolachlor applied pretransplanting incorporated (PTI) and pretransplanting (PRETR) at 1.07 (1×) and 2.14 (2×) kg ai ha−1. Severe injury was observed 6 wk after transplanting at the Whiteville environment in 2017 when S-metolachlor was applied PTI. End-of-season plant heights from PTI treatments at Whiteville were likewise reduced by 9% to 29% compared with nontreated controls, although cured leaf yield and value were reduced only when S-metolachlor was applied PTI at the 2× rate. Severe growth reduction was also observed at the Kinston location in 2018 where S-metolachlor was applied at the 2× rate. End-of-season plant heights were reduced 11% (PTI, 2×) and 20% (PRETR, 2×) compared with nontreated control plants. Cured leaf yield was reduced in Kinston when S-metolachlor was applied PRETR at the 2× rate; however, treatments did not impact cured leaf quality or value. Visual injury and reductions in stalk height, yield, quality, and value were not observed at the other three locations. Ultimately, it appears that injury potential from S-metolachlor is promoted by coarse soil texture and high early-season precipitation close to transplanting, both of which were documented at the Whiteville and Kinston locations. To reduce plant injury and the negative impacts to leaf yield and value, application rates lower than 1.07 kg ha−1 may be required in these scenarios.
Twenty-four new optically stimulated luminescence (OSL) and radiocarbon ages from sediment cores in nine lakes associated with the Shipshewana and Sturgis moraines in northern Indiana and southern Michigan estimate when recession of the Saginaw Lobe of the Laurentide Ice Sheet was underway in the southern Great Lakes region, USA. Average OSL ages of 23.4 ± 2.2 ka for the Shipshewana Moraine and 19.7 ± 2.2 ka for the Sturgis Moraine are considered minimum limiting deglacial ages for these recessional moraines. The much younger radiocarbon ages are consistent with other regional radiocarbon ages from lakes, and record climate amelioration around ~16.5 cal ka BP. Early recession of the interlobate Saginaw Lobe was well underway by 23.4 ± 2.2 ka, when the adjacent Lake Michigan and Huron-Erie lobes were a few hundred kilometers farther south and near their maximum southerly limits. The results provide the first time constraints when sediment from the Lake Michigan and Huron-Erie lobes began filling the accommodation space left by the Saginaw Lobe. The difference between the oldest radiocarbon and OSL age is 7400 yr for the Shipshewana Moraine and 3400 yr for the Sturgis Moraine.
Cannabis use has demonstrated an association with earlier onset of psychosis. Investigation of sociodemographic and clinical characteristics in association with cannabis use in adults with first-episode psychosis (FEP) has resulted in inconsistent findings. The clinical profile of cannabis users amongst adolescents with FEP remain widely understudied.
To investigate the frequency of cannabis use, and its association with sociodemographic and clinical characteristics in adolescent-versus adult-onset FEP.
Naturalistic cross-sectional study of 1363 FEP cases aged 14-35 (136 with adolescent-onset psychosis) referred to Early Intervention Services for psychosis in London (UK) (2003-2009). Sociodemographic and clinical data (age of psychosis onset, symptom domains, substance misuse, insight, violence, global functioning, and duration of untreated psychosis [DUP]) were collected at entry to EIS.
Cannabis users were more likely to be male (78.2%), White (43.0%) and unemployed (72.0%). No significant difference was found in cannabis abuse/dependence frequencies between adolescents (28.4%) and adults (24.7%). Cannabis abuse/dependence was associated with an earlier onset of psychosis by 2 years (p<0.001), greater manic and positive symptoms (p<0.001), increased violence (p=0.011), and poorer functioning (p=0.013) and insight (p=0.003). For adolescents, cannabis abuse/dependence was associated with greater positive symptoms, poorer functioning and longer DUP.
Cannabis use shapes the clinical presentation of FEP individuals. Similar frequencies of cannabis use between age groups suggest that substance misuse services should be provided to all, aiming to reducing consumption. Greater vigilance amongst clinicians would enable earlier detection of psychosis in substance misusing adolescents, to reduce DUP and minimise associated poor outcomes.
The importance of timely identification and treatment of psychosis are increasingly the focus of early interventions, with research targeting the initial high-risk period in the months following first-episode hospitalization. However, ongoing psychiatric treatment and service utilization after the symptoms have been stabilized over the initial years following first-episode has received less research attention.
To model the variables predicting continued service utilization with psychiatrists for adolescents following their first-episode psychosis; examine associated temporal patterns in continued psychiatric service utilization.
This study utilized a cohort design to assess adolescents (age 14.4 ± 2.5 years) discharged following their index hospitalization for first-episode psychosis. Bivariate analyses were conducted on predictor variables associated with psychiatric service utilization. All significant predictor variables were included in a logistic regression model.
Variables that were significantly associated with psychiatric service utilization included: diagnosis with a schizophrenia spectrum disorder rather than major mood disorder with psychotic features (OR = 24.0; P = 0.02), a first degree relative with depression (OR = 0.12; P = 0.05), and months since last psychiatric inpatient discharge (OR = 0.92; P = 0.02). Further examination of time since last hospitalization found that all adolescents continued service utilization up to 18 months post-discharge.
Key findings highlight the importance of early diagnosis, that a first degree relative with depression may negatively influence the adolescent's ongoing service utilization, and that 18 months post-discharge may a critical time to review current treatment strategies and collaborate with youth and families to ensure that services continue to meet their needs.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The discussion of evolutionary theory and feminist ideology has existed for decades and has been obstructed by assumptions, generalizations, misunderstandings, and omissions from both points of view. Terminology, in particular, has had important consequences for comprehension. We note, like Barkow (2006), that there is no term that accurately captures the variety of work of those applying Darwinian theory to the study of human behavior. We apply “evolutionary psychology” here as it is a prevalent term that is used currently, but it also reinforces the goal of focusing on human nature as an outcome of biological evolution (Barkow, 2006). To provide as much clarity and simplicity as possible in this chapter, we will refer to evolutionary scientists as “evolutionists” and feminist scholars as “feminists” as they were in Hrdy (1981/1999).
Recent investigations now suggest that cerebrovascular reactivity (CVR) is impaired in Alzheimer’s disease (AD) and may underpin part of the disease’s neurovascular component. However, our understanding of the relationship between the magnitude of CVR, the speed of cerebrovascular response, and the progression of AD is still limited. This is especially true in patients with mild cognitive impairment (MCI), which is recognized as an intermediate stage between normal aging and dementia. The purpose of this study was to investigate AD and MCI patients by mapping repeatable and accurate measures of cerebrovascular function, namely the magnitude and speed of cerebrovascular response (τ) to a vasoactive stimulus in key predilection sites for vascular dysfunction in AD.
Thirty-three subjects (age range: 52–83 years, 20 males) were prospectively recruited. CVR and τ were assessed using blood oxygen level-dependent MRI during a standardized carbon dioxide stimulus. Temporal and parietal cortical regions of interest (ROIs) were generated from anatomical images using the FreeSurfer image analysis suite.
Of 33 subjects recruited, 3 individuals were excluded, leaving 30 subjects for analysis, consisting of 6 individuals with early AD, 11 individuals with MCI, and 13 older healthy controls (HCs). τ was found to be significantly higher in the AD group compared to the HC group in both the temporal (p = 0.03) and parietal cortex (p = 0.01) following a one-way ANCOVA correcting for age and microangiopathy scoring and a Bonferroni post-hoc correction.
The study findings suggest that AD is associated with a slowing of the cerebrovascular response in the temporal and parietal cortices.
Social support has been shown to be associated with a reduced likelihood of developing psychotic experiences in the general population and even amongst those at high risk due to exposure to multiple forms of victimisation (poly-victimised). However, it is unclear whether this association is merely due to the confounding effects of shared environmental and genetic influences, or reverse causality. Therefore, we investigated whether social support has a unique environmentally mediated effect on adolescent psychotic experiences after accounting for familial factors, including genetic factors, and also prior psychopathology.
Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 UK-born twins. Adolescents were interviewed at age 18 about psychotic experiences and victimisation exposure since age 12, and their perceptions of social support. Prior childhood mental health problems and psychotic symptoms were assessed at age 12. The discordant twin method was used to disentangle the relative family-wide and unique-environmental effects of social support on psychotic experiences in the general population and among poly-victimised adolescents.
Perceived social support, particularly from friends, was found to have a unique environmentally mediated buffering effect on adolescent psychotic experiences in the whole sample and in the high-risk poly-victimised group.
The protective effects of social support on adolescent psychotic experiences cannot be accounted for by shared environmental or genetic factors, nor by earlier psychopathology. Our findings suggest that early intervention programmes focused on increasing perceptions of social support have the potential to prevent the emergence of psychotic experiences amongst adolescents.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
This article reviews the Southern Illinois Twins/Triplets and Siblings Study (SITSS) and describes some of the findings related to recent projects that were completed using this sample. At this time, the SITSS has enrolled 375 twin pairs, 12 triplet families, 1 family of quadruplets, 98 nontwin sibling pairs and 287 singletons. Testing begins for twins and triplets as young as age 1 and then occurs yearly on their birthdays until 5 years of age. Through age 20, various follow-up studies have been conducted on the SITSS sample to examine their social, emotional, and cognitive development across childhood and adolescence from a behavioral genetic perspective. A variety of methodologies have been used to investigate gene–environment correlations (rGE) and gene–environment interactions (GxE). Advanced statistical procedures (e.g., genetic likelihood indices and multilevel modeling) have been utilized to further investigate genetic underpinnings of behavior. Recent results have indicated genetic influences on the aggressiveness of preschoolers’ media preferences, increased problem behaviors related to young children’s overestimation of self-competence, and the influence of early life temperament and internalizing problems on adolescent health behaviors. Additionally, the SITSS has provided evidence for evocative rGE for various behaviors (aggression, prosocial and play), as well as findings supporting interactions between the dopamine receptor D4 gene (DRD4) and the environment (peer victimization, prenatal birth complications and parental sensitivity). Together, by use of multitrait and multimethodological investigations, this behavior genetic data set assists in furthering our understanding of biological and environmental influences on children’s development.
Background: Cervical sponylotic myelopathy (CSM) may present with neck and arm pain. This study investiagtes the change in neck/arm pain post-operatively in CSM. Methods: This ambispective study llocated 402 patients through the Canadian Spine Outcomes and Research Network. Outcome measures were the visual analogue scales for neck and arm pain (VAS-NP and VAS-AP) and the neck disability index (NDI). The thresholds for minimum clinically important differences (MCIDs) for VAS-NP and VAS-AP were determined to be 2.6 and 4.1. Results: VAS-NP improved from mean of 5.6±2.9 to 3.8±2.7 at 12 months (P<0.001). VAS-AP improved from 5.8±2.9 to 3.5±3.0 at 12 months (P<0.001). The MCIDs for VAS-NP and VAS-AP were also reached at 12 months. Based on the NDI, patients were grouped into those with mild pain/no pain (33%) versus moderate/severe pain (67%). At 3 months, a significantly high proportion of patients with moderate/severe pain (45.8%) demonstrated an improvement into mild/no pain, whereas 27.2% with mild/no pain demonstrated worsening into moderate/severe pain (P <0.001). At 12 months, 17.4% with mild/no pain experienced worsening of their NDI (P<0.001). Conclusions: This study suggests that neck and arm pain responds to surgical decompression in patients with CSM and reaches the MCIDs for VAS-AP and VAS-NP at 12 months.
Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.