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Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.
3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. “+risk” was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.
731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.
Significance of results
We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
We present a high-resolution spatial study of ocean surface carbon dioxide partial pressure (pCO2), temperature and salinity coupled with a seismic survey performed in subpolar waters with a variable presence of glaciers along the coastal margins of Admiralty Bay and the Bransfield Strait, northern Antarctic Peninsula, during the late spring season. Three zones were identified in this bay. The shallow and relatively fresh SHALLOW GLACIER THAW zone in the inner portion of the bay had high freshwater inputs from active glacial meltwater channels, representing higher pCO2 levels (median ~438 μatm) than the shallow and relatively salty SHALLOW zone without glaciers along the margins and dominated by macroalgae communities at the bottom, which showed relatively low pCO2 levels (median ~371 μatm). The deep and relatively salty CENTRE zone was highly influenced by seawater intrusions from the Bransfield Strait, representing intermediate pCO2 levels (median ~397 μatm). The net sea-air CO2 fluxes in late spring obtained from the high-resolution surface survey in Admiralty Bay indicate a condition of near neutral air-sea CO2 flux, with a median (25–75% interquartile range) value of -0.07 mmol m-2 day-1 (ranging from -12.21 to +4.33 mmol m-2 day-1), contrasting with the slight source to the atmosphere estimated from measurements only in the CENTRE zone. This finding suggests that temperature-sensitive metabolic and physical-chemical processes may cause significant variability in the ocean surface distribution of CO2 over short shoreline distances in the northern Antarctic Peninsula.
Oral nutritional supplements are widely recommended to head-and-neck cancer patients undergoing anti-cancer treatment; however, their effects on the outcomes of most importance to patients are unclear. This study aimed to systematically review the evidence of effect of oral nutritional supplements on mortality, treatment tolerance, quality of life, functional status, body weight and adverse effects. We searched PubMed, Embase, CENTRAL, LILACS, Web of Science, CINAHL, two trial registry platforms, three sources of grey literature and reference lists of included studies. We assessed the risk of bias using the revised Cochrane risk-of-bias tool (RoB 2), and certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. We used random-effects models with Hartung–Knapp correction for the meta-analyses. We included fifteen trials, of which five were ongoing or unpublished, providing evidence in four comparisons. We found very low to low certainty evidence for the effect of oral nutritional supplements on mortality, treatment tolerance, quality of life, functional status and adverse effects. When compared with nutritional counselling alone, nutritional counselling plus oral nutritional supplements probably increased body weight slightly. We also found adverse events relating to supplements use such as nausea, vomiting and feeling of fullness. Possible increases in mortality, treatment tolerance and quality of life besides a possible decrease in functional status are worthy of further investigation. Future research could attempt to address the clinical importance of a probable increase in body weight. Possible adverse effects of the use of oral nutritional supplements should not be overlooked.
Specimens of Stylops advarians were sampled by collecting foraging bees of Andrena milwaukeensis along the South Saskatchewan River within Saskatoon, Saskatchewan. As the foraging season progressed from early May till late June over three consecutive years (2016–2018), most stylopized bees possessed endoparasitic adult (neotenic) females of S. advarians protruding from the bee gaster's dorsum. In contrast, very few adult bees stylopized by male puparia, and no free-living males, were encountered. Over the sampling period, prevalence remained around 22% each year; mean intensity was 1.2 (range of 1–3 female parasites per bee); and parasite abundance was 0.27. Also newly reported for Stylops is the occurrence of one bee bearing four Stylops (two neotenic females and two males with puparia), plus another bee with a male puparium extruded from its gaster's sternites. Around 2 May each year, a high proportion of the earliest captured female bees were stylopized. However, non-stylopized female bees typically were not encountered until about 10 days later, suggesting the parasites manipulate female bee hosts to emerge earlier, in close synchrony to male bee emergence. First-instar larvae of S. advarians appeared from 22–25 May, indicating that adults of S. advarians matured and mated at similar times each season.
The production and use of masks at multiple scales and in diverse contexts is a millennia-long tradition in Mesoamerica. In this paper, we explore some implications of Mesoamerican masking practices in light of materiality studies and the archaeology of the senses. We also discuss a collection of 22 masks, miniature masks and representations of masks from the lower Río Verde valley of coastal Oaxaca, Mexico. The iconography of these artefacts as well as their recovery from well-documented archaeological contexts inform our interpretations of masking practices during an approximately 2000-year span of the Formative period (2000 bc–ad 250). Specifically, we argue that these masking-related artefacts index sociocultural changes in the region, from the first villages and the advent of ceramic technology during the Early Formative period (2000–1000 bc) to a time of increasing consolidation of iconographic influence in the hands of the elite in the final centuries before the Classic period. As indicated by their continued use today, masks have long been intimates of communal activities in Oaxaca.
In 2008, four decades since Meldgaard's work at Alarniq—the type site for Dorset culture—Savelle and Dyke returned to resurvey the site. Archaeological investigations continued in 2015 and 2017 as part of the Foxe Basin Archaeological Project, when Howse conducted further surveys, excavated six semi-subterranean dwellings and two associated middens, and tested five additional features. The new site map and radiocarbon sequence have significantly changed our understanding of site use and beach-level chronology at Alarniq. The number of dwellings varies across the beach ridges, suggesting populations fluctuated throughout the site's use (2,700–800 cal BP). However, the new radiocarbon analyses also indicate that dwellings between 14.5 and 21.5 m above sea level are the same general age and that paleodemography at Alarniq is less straightforward than suggested by the number of features per beach ridge. It appears that ideal house construction location is a stronger indicator of the placement of winter houses at the site than proximity to the shoreline. We suggest this is largely related to site seasonality. These new data have significant implications for our understanding of current Dorset artifact typologies that have largely been developed using the material Meldgaard recovered at the site.
The electrochemical discharge mechanism is reported for all-solid lithium sulfur batteries. Upon milling with carbon fibers, the solid electrolyte used within the cathode composite becomes electrochemically active. Analysis with Raman spectroscopy and XPS revealed the importance of bridging S-S bond formation and breaking in lithium polysulfidophosphates during electrochemical lithiation of the active solid electrolyte. Remarkably, when sulfur is introduced as an active material in the cathode composite, lithium polysulfides are formed as an intermediate product before full lithiation into lithium sulfide. The synthesis of materials based on bridging S-S bonds is an important avenue to the design of new cathodes for all-solid batteries.
Archaeological sites in the Canadian Arctic often contain substantial quantities of marine mammal bones and in some cases completely lack terrestrial mammal bones. A distrust of radiocarbon (14C) dates on marine mammal bones among Arctic archaeologists has caused many sites to be insufficiently dated. The goal of this study was to investigate the marine reservoir effect on Atlantic walrus in the Foxe Basin region of the Canadian Arctic through a two-pronged approach: dating of live-harvested specimens of known age collected prior to AD 1955 and dating of pairs of animal remains (walrus and caribou) from stratigraphically contemporaneous levels within archaeological features. 14C dates on pre-bomb, live-harvested walrus indicate that a ΔR value of 160±50 yr be used in calibrating dates on walrus from this region. These results differed significantly from a similar set of pre-bomb mollusks, which argues against applying mollusk-based corrections to marine mammals. The results of comparative dating of caribou and walrus from archaeological features provided maximum estimates of reservoir ages that were more varied than the directly measured ages. Although about half of inferred ΔR values overlap the museum specimen results, the others indicate that the assumption of contemporaneity does not hold true.
Midpassages are the most recognizable architectural feature associated with the entire Paleoeskimo period (2800 BC–AD 1300) in the Canadian and Greenlandic Arctic. Usually built of stone, midpassages are rectangular-shaped axial structures that run through the center of tent rings and semisubterranean house depressions. However, a unique triangular form of midpassage developed in association with the Late Dorset complex in the Boothia Peninsula area of the Canadian Arctic around AD 400. Unlike the rectangular-shaped varieties that were built contemporaneously across the Arctic, distribution of the triangular form is limited, and occurrences are rare. Initially, construction appears restricted to the Boothia Peninsula region, where the form persisted for the subsequent 400 years. After AD 900, they are found in Inglefield Land, Greenland, and a few other locations in the Canadian Arctic where they continued to be built until around AD 1200, representing an over 800-year period in a remarkably unvarying configuration. Further, these triangular midpassage structures very likely represent a regional architectural variant that moved northward with the Late Dorset diaspora after AD 800.
Introduction: The proportion of Canadians receiving anticoagulation medication is increasing. Falls in the elderly are the most common cause of minor head injury and an increasing proportion of these patients are prescribed anticoagulation. Emergency department (ED) guidelines advise performing a CT head scan for all anticoagulated head injured patients, but the risk of intracranial hemorrhage (ICH) after a minor head injury (patients who have a Glasgow comma score (GSC) of 15) is unclear. We conducted a systematic review and meta-analysis to determine the point incidence of ICH in anticoagulated ED patients presenting with a minor head injury. Methods: We systematically searched Pubmed, EMBASE, Cochrane database, DARE, google scholar and conference abstracts (May 2017). Experts were contacted. Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) guidelines were followed with two authors reviewing titles, four authors reviewing full text and four authors performing data extraction. We included all prospective studies recruiting consecutive anticoagulated ED patients presenting with a head injury. We obtained additional data from the authors of the included studies on the subset of GCS 15 patients. We performed a meta-analysis to estimate the point incidence of ICH among patients with a GCS score of 15 using a random effects model. Results: A total of five studies (and 4,080 GCS 15, anticoagulated patients) from the Netherlands, Italy, France, USA and UK were included in the analysis. One study contributed 2,871 patients. Direct oral anticoagulants were prescribed in only 60 (1.5%) patients. There was significant heterogeneity between studies with regards to mechanism of injury, CT scanning and follow up method (I2 =93%). The random effects pooled incidence of ICH was 8.9% (95% CI 5.0-13.8%). Conclusion: We found little data to reflect contemporary anticoagulant prescribing practice. Around 9% of warfarinized patients with a minor head injury develop ICH. Future studies should evaluate the safety of selective CT head scanning in this population.
Loess is widespread over Alaska, and its accumulation has traditionally been associated with glacial periods. Surprisingly, loess deposits securely dated to the last glacial period are rare in Alaska, and paleowind reconstructions for this time period are limited to inferences from dune orientations. We report a rare occurrence of loess deposits dating to the last glacial period, ~19 ka to ~12 ka, in the Yukon-Tanana Upland. Loess in this area is very coarse grained (abundant coarse silt), with decreases in particle size moving south of the Yukon River, implying that the drainage basin of this river was the main source. Geochemical data show, however, that the Tanana River valley to the south is also a likely distal source. The occurrence of last-glacial loess with sources to both the south and north is explained by both regional, synoptic-scale winds from the northeast and opposing katabatic winds that could have developed from expanded glaciers in both the Brooks Range to the north and the Alaska Range to the south. Based on a comparison with recent climate modeling for the last glacial period, seasonality of dust transport may also have played a role in bringing about contributions from both northern and southern sources.
Patient days and days present were compared to directly measured person time to quantify how choice of different denominator metrics may affect antimicrobial use rates. Overall, days present were approximately one-third higher than patient days. This difference varied among hospitals and units and was influenced by short length of stay.
Most commonly used models for turbulent mixing in the ocean rely on a background stratification against which turbulence must work to stir the fluid. While this background stratification is typically well defined in idealized numerical models, it is more difficult to capture in observations. Here, a potential discrepancy in ocean mixing estimates due to the chosen calculation of the background stratification is explored using direct numerical simulation data of breaking internal waves on slopes. Two different methods for computing the buoyancy frequency
, one based on a three-dimensionally sorted density field (often used in numerical models) and the other based on locally sorted vertical density profiles (often used in the field), are used to quantify the effect of
on turbulence quantities. It is shown that how
is calculated changes not only the flux Richardson number
, which is often used to parameterize turbulent mixing, but also the turbulence activity number or the Gibson number
, leading to potential errors in estimates of the mixing efficiency using
In this paper, we examine a Terminal Formative-period (150 bc–ad 250) bundled offering from the site of Cerro de la Virgen, located on the Pacific coast of Oaxaca, Mexico. The offering was emplaced below a prominent public building in the site's ceremonial centre and contained five stone objects, including a rain deity mask, a fragment of a second mask, a figurine of a deceased ancestor and two miniature table altars, as well as nine small ceramic vessels. Considered together as a ‘sacred bundle’, the stone objects collectively reference agricultural fertility, rulership and ancestor veneration, which we interpret to be a metaphorical invocation of a fundamental tenet of prehispanic Mesoamerican religious belief—the sacred covenant. The offering also played an active part in founding the community of Cerro de la Virgen, connecting its residents with the divine, the ancestors and the outside world and constituting differences in status among its members.