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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.
Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed.
We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach.
Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI.
Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
The Metabolic Syndrome (MetS) is a constellation of markers which often coexist in patients, each representing an increased risk of developing cardiovascular disease. It is established that the prevalence of MetS among schizophrenic patients is greatly increased compared to the general population. This effect is mostly attributed to use of atypical antipsychotic medications, however questions also exist over whether schizophrenia itself can contribute more directly to metabolic dysfunction. Indeed metabolic disturbances were common in mental illness as early as 1879, many years before the implementation of antipsychotic medications.
We evaluated the link between MetS and schizophrenia which is independent of antipsychotics, by conducting a systematic literature search of Pubmed (2002-2012) for studies of drug-naive and first episode patients. 12 papers met our criteria, from which 893 patients were evaluated. An average prevalence of MetS across these studies was 10.8%. We found that there are very few data to suggest that the incidence of MetS is increased in first episode and drug naive adult patients with schizophrenia. It appears, however, that schizophrenia does increase some components of MetS, such as diabetes.
Many contributory mechanisms have been proposed for the observed metabolic dysregulation in schizophrenic patients. There include hypothalamic-pituitary axis dysfunction, sympathetic nervous system dysfunction, proinflammatory states and several genetic mutations, however much controversy exists in this area.
There is a huge cardiovascular burden on schizophrenic patients, accounting for 50% of natural excess deaths. It is crucial, therefore, to establish the causes and optimal management of MetS in schizophrenia.
Novel commercially available software has enabled registration of both CT and MRI images to rapidly fuse with X-ray fluoroscopic imaging. We describe our initial experience performing cardiac catheterisations with the guidance of 3D imaging overlay using the VesselNavigator system (Philips Healthcare, Best, NL). A total of 33 patients with CHD were included in our study. Demographic, advanced imaging, and catheterisation data were collected between 1 December, 2016 and 31 January, 2019. We report successful use of this technology in both diagnostic and interventional cases such as placing stents and percutaneous valves, performing angioplasties, occlusion of collaterals, and guidance for lymphatic interventions. In addition, radiation exposure was markedly decreased when comparing our 10–15-year-old coarctation of the aorta stent angioplasty cohort to cases without the use of overlay technology and the most recently published national radiation dose benchmarks. No complications were encountered due to the application of overlay technology. 3D CT or MRI overlay for CHD intervention with rapid registration is feasible and aids decisions regarding access and planned angiographic angles. Operators found intraprocedural overlay fusion registration using placed vessel guidewires to be more accurate than attempts using bony structures.
Pharmacogenetic studies in obsessive-compulsive disorder (OCD) primarily focussing on serotonergic and dopaminergic polymorphisms, provided inconsistent findings. There is recent evidence for glutamatergic abnormalities in OCD.
Examine the association glutamatergic genes with serotonin reuptake inhibitor (SRI) response in OCD.
To study pharmacogenetic association between SLC1A1 and GRIN2B polymorphisms with SRI response in OCD.
DSM-IV OCD patients were recruited from a specialty OCD clinic and evaluated using the Yale-Brown obsessive compulsive scale (YBOCS), Mini International Neuropsychiatric Interview (MINI) plus, Clinical Global Impression scale (CGI). They were subsequently reassessed with YBOCS and CGI. To study extreme phenotypes, we included only full responders (> 35% YBOCS improvement and CGI-I score of 1 or 2) to any SRI (n = 191) and non-responders (< 25% YBOCS improvement and CGI-I score ≥ 4) to adequate trial of at least two SRIs (n = 84). Partial responders were excluded. Genotyping was performed using an ABI9700 PCR machine.
Genotype frequencies did not deviate significantly from the values predicted by the Hardy-Weinberg equation. Case-control association analyses revealed no significant association between genotype/allele frequencies with SRI response.
Our data does not show any association between polymorphisms in glutamatergic genes and SRI response in OCD though such associations have been found in other studies. More SNP's in the same gene could be responsible for the pharmacogenetic associations. More homogenous sample considering symptom dimensions and other phenotypic variables may be needed. It may be critical to go beyond “usual suspect” candidate gene research. In this regard, a novel approach to identify SRI response biomarkers is the use of cellular models.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A substantial number of patients suffering from obsessive compulsive disorder (OCD) report a subjective distressing experience prior to the repetitive behavior, known as sensory phenomena(SP).
Need to systematically evaluate SP and the clinical correlates in OCD.
Assess prevalence of SP and clinical correlates in OCD.
Subjects (n = 71) fulfilling the criteria for DSM IV-TR OCD were recruited consecutively from a specialty OCD clinic in Southern India and were assessed using the Yale brown obsessive and compulsive scale (YBOCS), dimensional Yale-Brown obsessive compulsive scale (D-YBOCS) and the University of São Paulo Sensory Phenomena Scale (USP-SPS).
The prevalence of the SP was found to be 50.7%. Prevalence of SP is significantly greater in the patients with early age of onset (P = 0.47). In subtypes of SP, Tactile was 12.7%, “just right” for look was 26.8%, “just right” for sound was 9.9%, “just right” for feeling was 16.9%, feeling of incompleteness leading to repetitive behavior was 22.5%, “energy release” sensation leading to repetitive behavior was 4.2% and “urge only” leading to repetitive behavior was 11.3%. SP was found to have significant correlation with symmetry/ordering/arranging/counting dimension (P = 0.003). Significant positive correlation existed between SP severity and the severity of the compulsions (P = 0.02).
Considering its high prevalence in OCD, it might be useful to incorporate SP assessment during the routine clinical assessment of OCD. It might warrant a place in the phenomenological and nosological description of OCD. Additionally, the neurobiological correlates of SP need to be explored.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Contemporary treatment guidelines recommend use of second-generation antipsychotics (SGAs) either as mono therapy or in combination with mood stabilizers as first-line treatment. While these drugs have been established to have superior efficacy compared to placebo, there is very less data comparing these antipsychotics with one another. We sought to study differences in the five-year outcome of first episode of mania (FEM) treated with olanzapine or risperidone, either alone or in combination with mood stabilizer.
We conducted a retrospective chart review of patients diagnosed with FEM (ICD-10) in the year 2008 (n = 88) at our centre. We selected the data of patients prescribed either olanzapine or risperidone for the purpose of this analysis. We extracted data about time to recovery and recurrence after FEM, total episodes, drug compliance and response, and number of follow-up visits from 2008 to 2013. The study was approved by the Institute Ethics Committee.
A total of 88 patients received diagnosis of FEM in the year 2008, of which 50 (56.8%) received risperidone and 35 (39.8%) received olanzapine. The two groups were comparable in socio-demographic and clinical symptomatology of FEM (all P > 0.08). Complete recovery was significantly more in the olanzapine group than the risperidone group (χ2 = 4.84, P < 0.05).
Our study indicates that risperidone and olanzapine, either alone or in combination with mood stabilizers have a similar impact on the five-year course of BD following a first manic episode. However, olanzapine is associated with more complete recovery from FEM than risperidone.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Trait-specific characterization of rice landraces has significant potential for germplasm management, varietal identification and mining of novel gene/allele for various traits. In the current study, we have characterized 98 unique rice landraces collected from coastal regions of India, affected by submergence and salinity, based on Sub1 and Saltol quantitative trait loci (QTL) linked microsatellite markers. Among these genotypes, four genotypes (IC536558, IC536559, IC536604 and IC536604-1) collected from Kerala and two genotypes (AC34902 and IC324589) collected from West Bengal were identified with tolerance to submergence and salinity stress. A high level of genetic diversity of He = 0.349 and 0.529 at Sub1 and Saltol QTL region was detected by QTL-linked microsatellite markers, respectively. At Sub1 region one genotype, AC34902, was detected with maximum allelic similarity with FR13A, a known submergence tolerant variety. Besides, five genotypes (IC211188-1, IC536604-1, IC536604, IC536558 and IC536559) showed comparatively close genetic relationship with the salt tolerant variety FL478 for Saltol QTL and were clustered together in the neighbour joining dendrogram. Considering the haplotype structure, five genotypes (IC203801, IC203778, IC324584, IC413608 and IC413638) were identified which did not contain any common allele similar to FR13A but were still tolerant to submergence. These individuals need further characterization for identification of new alleles responsible for their tolerance.
Background: Post-craniotomy pain can be severe and undermanaged. While opioids are the mainstay treatment, they have the potential to interfere with neurological monitoring. The objectives of this review are: 1) to identify measures to provide opioid-free analgesia 2) to compare the effectiveness of non-opioid to opioid analgesia in post-craniotomy pain. Methods: A comprehensive search of EMBASE, MEDLINE, and the Cochrane Central Registry of Controlled Trials (CENTRAL) databases was conducted for RCTs evaluating the effect of opioid vs non-opioid pain control strategies in patients undergoing supratentorial craniotomy. Results: The literature search yielded 462 citations, 5 RCTs that met the inclusion criteria for a total of 250 patients. Scalp infiltration/block was found to provide equivalent analgesia to morphine1 and fentanyl.2 Morphine was associated with slightly higher postoperative nausea and vomiting. Paracetamol was less likely to induce nausea and vomiting,3,4 but provided inadequate pain relief compared to nalbuphine,3 tramadol,3 morphine4 and sufentanil.4 Dexmedetomidine5 provided similar analgesia to remifentanil but did delay the time to first dose of rescue analgesia with similar side effects. Conclusions: Based on the limited number of RCTs comparing opioid to non-opioid techniques, no definite recommendations can be made with regards to the optimal management of post-craniotomy pain. Considerations should be made for use of multimodal analgesia-including adjuvant analgesics.
The meteoroid ablation is an important source of upper atmosphere metal atoms. Many meteoroids ablate between 70 - 110 km and form an ionized plasma trail which is detected by radar technique. It is also known that the ablation heights of the meteors depend on various factors such as velocity, mass, and its composition, etc. The meteor ablation height provides new opportunities to gather information on the neutral atmosphere in the Mesosphere and Lower Thermosphere (MLT) region. In this study, we analysed the 11 years of meteor radar data (2005 - 2015), i.e., descending phase of solar cycle 23, and ascending phase of solar cycle 24, detected by all sky meteor radar at Thumba. We found that the solar activity influences the meteor ablation height, here, during the solar maxima meteor peak detection height rise to few hundred meters higher altitudes. We also examined the long term pattern of the meteor count rate which shows a decreasing trend and has good agreement with the sunspot number (SSN).
In the southeastern United States, Amaranthus, or pigweed species, have become troublesome weeds in agricultural systems. To implement management strategies for the control of these species, agriculturalists need information on areas affected by pigweeds. Geographic information systems (GIS) afford users the ability to evaluate agricultural issues at local, county, state, national, and global levels. Also, they allow users to combine different layers of geographic information to help them develop strategic plans to solve problems. Furthermore, there is a growing interest in testing free and open-source GIS software for weed surveys. In this study, the free and open-source software QGIS was used to develop a geographic information database showing the distribution of pigweeds at the county level in the southeastern United States. The maps focused on the following pigweeds: Palmer amaranth, redroot pigweed, and tall waterhemp. Cultivated areas and glyphosate-resistant (GR) pigweed data were added to the GIS database. Database queries were used to demonstrate applications of the GIS for precision agriculture applications at the county level, such as tallying the number of counties affected by the pigweeds, identifying counties reporting GR pigweed, and identifying cultivated areas located in counties with GR pigweeds. This research demonstrated that free and open-source software such as QGIS has strong potential as a decision support tool, with implications for precision weed management at the county scale.
In the present paper, we analyzed the effects of magnetic field on the three dimensional flow of a nanofluid having the suspension of ferrous nano-particles within the framework of a non-uniformly thicked sheet in a slip flow regime. The sheet of variable thickness is assumed to be stretched in horizontal and transverse directions. The effects of thermophoretic forces and Brownian motion have also been incorporated into the governing equations. The RK-Fehlberg-integration scheme with shooting technique is employed to resolve the altered governing non-linear differential equations. Velocity, temperature and concentration profiles are presented and discussed for two cases namely uniform thickness stretching sheet UTSS (n = 1) and variable thickness stretching sheet VTSS (n ≠ 1), and skin friction coefficient, reduced Nusselt number and Sherwood number are computed and analyzed through tables. The results reveal that heat and mass transfer processes over slendering sheet matches with those over a flat sheet in the presence of slip flow regime.
Precision weed management, an application of precision agriculture, accounts for within-field variability of weed infestation and herbicide damage. Unmanned aerial vehicles (UAVs) provide a unique platform for remote sensing of field crops. They are more efficient and flexible than manned agricultural airplanes in acquiring high-resolution images at low altitudes and low speeds. UAVs are more universal than agricultural aircraft, because the latter are used only in specific regions. We have developed and used UAV systems for red–green–blue digital and color–infrared imaging over crop fields to identify weed species, determine crop injury from dicamba at different doses, and detect naturally grown glyphosate-resistant weeds. This article presents remote sensing technologies for weed management and focuses on development and application of UAV-based low-altitude remote sensing technology for precision weed management. In particular, this article futher discusses the potential application of UAV-based plant-sensing systems for mapping the distributions of glyphosate-resistant and glyphosate-susceptible weeds in crop fields.
Difficult terrain and inclement weather limit our knowledge of large predators, such as the tiger Panthera tigris, in the Himalayas. A lack of empirical data on large carnivores can lead to mismanagement of protected areas and population declines. We used non-invasive genetic and remote sensing data to inform the management of such high-altitude protected areas. We used the tiger as a focal species to investigate prey preference and habitat suitability in India's Buxa Tiger Reserve, which encompasses several eco-geographical regions in the Himalayan and subtropical zones. During 2010–2013, 909 faecal samples were collected, of which 372 were confirmed, using genetic analysis, to be of tiger origin. Fourteen prey species/groups were identified in 240 tiger faecal samples, largely dominated by goats Capra spp. (26.59%), rhesus macaques Macaca mulatta (22.22%) and cattle Bos spp. (20.63%). Considering only the wild prey species for which survey data are available, however, and frequency of occurrence of prey in faecal samples, hog deer Axis porcinus, sambar deer Rusa unicolor and spotted deer Axis axis were the most preferred prey species. Using faecal sample locations to examine the relationship between tiger presence and environmental features indicated that the niche for tigers is narrower than the available protected area: c. 62% of core protected area is suitable, of which only 17% is highly suitable for tigers. Tigers prefer dense vegetation, open forests, riverine vegetation and areas close to water sources. Faecal sample-based studies have the potential to generate data that can help us understand the ecology of elusive carnivore species inhabiting high-altitude landscapes.
Background: Iatrogenic dural tear a complication of spinal surgery with significant morbidity and cost to the healthcare system. The optimal management is unclear, and therefore we aimed to survey current practices among Canadian practitioners. Methods: A questionnaire was administered to members of the Canadian Neurological Surgeon’s Society designed to explore methods of closure of iatrogenic durotomy. Results: Spinal surgeons were surveyed with a 55% response rate (n=91). For pinhole sized tears there is a trend toward sealant fixation(36.7%). Medium and large sized tears are predominantly closed with sutures and sealant(67% and 80%, respectively). Anterior tears are managed using sealant alone(48%). Posterior tears are treated with a combination of sutures and sealant(73.8%). Nerve root tears are treated with either sealant alone(50%). Most respondents recommended bed rest for at least 24 hours in the setting of medium(73.2%) and large(89.1%) dural tears. Conclusions: This study elucidates the areas of uncertainty with regard to iatrogenic dural tear management. There is disagreement regarding management of anterior and nerve root tears, pin-hole sized tears in any location of the spine, and whether patients should be admitted to hospital or on bed-rest following a pin-hole sized dural tear. There is a need for a robust comparative research study of dural repair strategies.
Background: Surgery to remove dumbbell nerve sheath tumors (NST) is complex, and is accompanied by significant operative and perioperative challenges. Historically, resection of dumbbell NST required large operations involving opening the chest and laminectomy, often accompanied by instrumentation. We describe a case series of 5 patients who underwent single stage thorascopic-guided resection of dumbbell schwannoma at our institution. Methods: 5 cases presented consisted of moderate to large NST, which contained intraforaminal components. Tumor location ranged from T3-T9, with most tumors spanning 2-3 vertebral bodies. Presentation ranged from discomfort/pain (most common) to one presentation of neurologic deficit with difficulty with ambulation. Results: Thorascopic assisted resection accomplished gross total resection in 4 of the 5 cases. In all cases there was no significant neurologic deficit, although one patient reported transient numbness following the operation and all patients made significant improvement post operatively. The length of stay for these cases ranged from 1-6 days. Conclusions: Thorascopic assisted resection of dumbbell NST can be performed safely and with good outcomes by using the corridor the tumor produces. This approach reduces the need for instrumentation, length of stay and post operative complication rates relative to traditional approaches. To perform this approach effectively, good co-operation between the neurosurgeon and thoracic surgeon needs to be present.
The present study investigates the flow and heat transfer characteristics of blood carrying gold nanoparticles in a porous channel with moving/stationary walls in the presence of thermal radiation. Blood is considered as Newtonian fluid which is the base fluid and gold (Au) as nanoparticles. The governing equations are transformed into system of ordinary differential equations by using similarity transformations. The analytical solutions are obtained for the flow variables by employing homotopy analysis method (HAM). The analytical solutions are compared with the numerical solutions which are obtained by shooting technique along with Runge-Kutta scheme. It was noticed that there is a good agreement between analytical and numerical results. The influence of various parameters on velocity, temperature and heat transfer rate of gold-blood nanofluid has been discussed in detail. The temperature of the nanofluid increases with increasing the nanoparticle volume fraction. The heat transfer rate at the top wall increases with increasing nanoparticle volume fraction while it decreases for a given increase in radiation parameter.
A male child, with d-transposition of great arteries, a large perimembranous ventricular septal defect, multiple additional ventricular septal defects, small muscle-bound right ventricle, and severe pulmonary stenosis with confluent, moderate-sized branch pulmonary arteries, underwent an emergency right modified Blalock–Taussig shunt on day 15 of life and réparation à l’étageventriculaire procedure with ventricular septal defect closure with takedown of the Blalock–Taussig shunt at 2.5 years of age. On follow-up, he showed a moderate residual upper ventricular septal defect and multiple apical ventricular septal defects, mild mid-right pulmonary artery stenosis, free pulmonary regurgitation, and right ventricular dysfunction. Surgical re-intervention was deemed extremely risky, the upper muscular ventricular septal defect was closed using an 8-mm Amplatzer Muscular Ventricular Septal Defect Occluder Device, and an 18 mm Amplatzer Multi-Fenestrated Septal Occluder – Cribriform was used for the multiple apical muscular ventricular septal defects. After 1 year, his right pulmonary artery stenosis worsened, for which right pulmonary artery angioplasty was carried out using an 8×20 mm cutting balloon followed by a 10×20 mm Tyshak II balloon. This is the only case reported for the paediatric age group using a cribriform septal occluder device for percutaneous closure of multiple apical ventricular septal defects.