Consensus-Based Treatment Approaches for Managing Concerning Behaviors in Patients on Long-term Opioid Therapy for Chronic Pain: Case-Based Applications

Guidelines recommend careful monitoring of patients on long-term opioid therapy for chronic pain to assess for concerning medication-taking behaviors that may signal opioid misuse or the presence of a substance use disorder. However, specific management strategies to guide providers if concerning medication-taking behaviors emerge are lacking. Therefore, we recruited a Delphi panel—42 experts in chronic pain and opioid prescribing—to develop consensus-based treatment approaches to guide management of the 6 most common and concerning behaviors identified: missing prescriber appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. The results of that process are published as a separate study. The purpose of the present study was to present clinical cases in which concerning medication-taking behaviors arise in the course of long-term opioid therapy and demonstrate for readers how the Delphi panel’s consensus-based approaches could be applied.

Correction to: Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: a Delphi Study

In this paper, the author degrees were presented incorrectly. The correct listing is above.

Splenic trauma in the twenty-first century: changing trends in management

Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.

The NF-κB Activating Pathways in Multiple Myeloma

Multiple myeloma(MM), an incurable plasma cell cancer, represents the second most prevalent hematological malignancy. Deregulated activity of the nuclear factor kappaB (NF-κB) family of transcription factors has been implicated in the pathogenesis of multiple myeloma. Tumor microenvironment-derived cytokines and cancer-associated genetic mutations signal through the canonical as well as the non-canonical arms to activate the NF-κB system in myeloma cells. In fact, frequent engagement of both the NF-κB pathways constitutes a distinguishing characteristic of myeloma. In turn, NF-κB signaling promotes proliferation, survival and drug-resistance of myeloma cells. In this review article, we catalog NF-κB activating genetic mutations and microenvironmental cues associated with multiple myeloma. We then describe how the individual canonical and non-canonical pathways transduce signals and contribute towards NF-κB -driven gene-expressions in healthy and malignant cells. Furthermore, we discuss signaling crosstalk between concomitantly triggered NF-κB pathways, and its plausible implication for anomalous NF-κB activation and NF-κB driven pro-survival gene-expressions in multiple myeloma. Finally, we propose that mechanistic understanding of NF-κB deregulations may provide for improved therapeutic and prognostic tools in multiple myeloma.

Pediatric renal transplantation: A retrospective single-center study on epidemiology and morbidity due to EBV

Pediatric R-Tx patients are at high risk of developing EBV primary infection. Although high DNA replication is a risk factor for PTLD, some patients develop PTLD with low viral load. In this retrospective single-center study including all pediatric patients having received R-Tx (2003-2012 period), we aimed to identify risk factors for uncontrolled reactions to EBV (defined as the presence of a viral load >10 000 copies/mL or PTLD). A Cox proportional hazard model was performed. A total of 117 patients underwent R-Tx at a mean age of 9.7 ± 5.3 years, 46 of them being seronegative for EBV at the time of R-Tx. During follow-up, 54 patients displayed positive EBV viral load, 22 of whom presenting with primary infection. An uncontrolled reaction to EBV was observed in 24 patients, whilst 4 patients developed PTLD. Univariate and multivariate analyses suggested the following risk factors for an uncontrolled reaction: age below 5 years, graft from a deceased donor, ≥5 HLA mismatches, EBV-seronegative status at the time of R-Tx, and a secondary post-Tx loss of anti-EBNA. Monitoring anti-EBNA after R-Tx may contribute to the early identification of patients at risk for uncontrolled reaction.

Remarkable charge-transfer mobility from [6] to [10]phenacene as a high performance p-type organic semiconductor

The relationship between structure and charge transport properties of phenacene organic semiconductors has been studied with focus on [6] → [10]phenacene. Upon inserting phenyl rings, the π-extended structure results in strong electronic coupling interactions and reduction of reorganization energy. Using the classical Marcus charge transport theory, we predict that hole mobility in the phenacene series increases gradually up to 8.0 cm2 V-1 s-1 at [10]phenacene. This is remarkably high among other discovered OSCs, surpassing that of pentacene. Moreover, we notice that the experimental hole mobility of [6]phenacene is unusually low, inconsistent with other members in the same series. Thus, we performed full structural relaxation on phenacene and revealed similarities between theoretical and experimental crystal structures for all the members except [6]phenacene. We propose a new structure of [6]phenacene under the consideration of van der Waals force with smaller lattice parameters a* and b* compared to the experimental structure. Our new structural calculation fits well with the existing trend of hole mobility, energy gaps, effective masses, bandwidth and lattice parameters. Single-shot G0W0 calculations are performed to verify our structures. The results give a hint that the improvement in [6]phenacene efficiency lies on the intermolecular distance along the stacking direction of the crystal. Phenacene compounds generally have small effective masses, high charge transfer integrals and moderate reorganization energies necessary for hole transport. Our results suggest that the phenacene series, in particular [6] → [10]phenacene, have high charge mobility and air stability essential for achieving high efficiency electronic devices.

Meta-analysis of classical swine fever prevalence in pigs in India: A 5-year study

Aim:

The aim of the study was to determine the overall prevalence of classical swine fever (CSF) in pigs in India, through a systematic review and meta-analysis of published data.

Materials and Methods:

Consortium for e-Resources in Agriculture, India, Google Scholar, PubMed, annual reports of All India Coordinated Research Project on Animal Disease Monitoring and Surveillance, and All India Animal Disease database of NIVEDI (NADRES) were used for searching and retrieval of CSF prevalence data (seroprevalence, virus antigen, and virus nucleic acid detection) in India using a search strategy combining keywords and related database-specific subject terms from January 2011 to December 2015 in English only.

Results:

A total of 22 data reports containing 6,158 samples size from 18 states of India were used for the quantitative synthesis, and overall 37% (95% confidence interval [CI]=0.24, 0.51) CSF prevalence in India was estimated. The data were classified into 4 different geographical zones of the country: 20% (95% CI=0.05, 0.55), 31% (95% CI=0.18, 0.47), 55% (95% CI=0.32, 0.76), and 34% (95% CI=0.14, 0.62). CSF prevalence was estimated in northern, eastern, western, and southern regions, respectively.

Conclusion:

This study indicates that overall prevalence of CSF in India is much lower than individual published reports.

Systematic versus sentinel-lymph-node-driven axillary-lymph-node dissection in clinically node-negative patients with operable breast cancer. Results of the GF-GS01 randomized trial

Purpose

Sentinel-lymph-node (SLN) resection seems to minimize systematic axillary-lymph-node dissection (sALND) side effects in operated breast cancer patients. We explored whether SLN resection achieves similar therapeutic outcomes as sALND but with fewer side effects.

Methods

A randomized, controlled, open-label trial with parallel-group design compared sALND restricted to cases with positive SLN biopsy (test arm, n = 774) versus SLN biopsy followed by sALND (control arm, n = 770).

Results

The five-year overall survivals in control and test arms were 96.42 and 95.64% (P = 0.2925). The estimated difference was nearly zero (precisely, − 0.79%, one-tailed 95% confidence interval (CI) limit − 2.44%). In a multivariate Cox model, the adjusted hazard ratio in the test arm was HR 0.81 (upper 95% CI limit 1.17). Advanced age (HR 1.05 per additional year, CI [1.03–1.08]), negative progesterone receptor (HR 2.17 [1.35–3.45]), SLN metastasis (HR 1.69 [1.03–2.79]), and only one SLN identification technique (HR 4.14 [1.21–14.18]) were associated with lower survival. Patients with ≥ 1 severe side effect at 1 month in control and test arms were 173/703 = 24.6% [21.5–28.0%] and 91/693 = 13.1% [10.7–15.9%] (P < 0.001). The estimated sensitivity of SLN biopsy (control arm) was 145/178 = 81.5% [74.8–86.7%].

Conclusions

Restricting ALND to cases with positive SLN biopsy does not affect the overall survival but reduces by 11.5% [7.5–15.6%] (P < 0.001) the risk of severe short-time side effects of sALND.

D-Meson Azimuthal Anisotropy in Midcentral Pb-Pb Collisions at sqrt[s]_{NN}=5.02 TeV

The azimuthal anisotropy coefficient v_{2} of prompt D^{0}, D^{+}, D^{*+}, and D_{s}^{+} mesons was measured in midcentral (30%-50% centrality class) Pb-Pb collisions at a center-of-mass energy per nucleon pair sqrt[s_{NN}]=5.02  TeV, with the ALICE detector at the LHC. The D mesons were reconstructed via their hadronic decays at midrapidity, |y|<0.8, in the transverse momentum interval 1<p_{T}<24  GeV/c. The measured D-meson v_{2} has similar values as that of charged pions. The D_{s}^{+} v_{2}, measured for the first time, is found to be compatible with that of nonstrange D mesons. The measurements are compared with theoretical calculations of charm-quark transport in a hydrodynamically expanding medium and have the potential to constrain medium parameters.

Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

BACKGROUND

Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed.

OBJECTIVE

To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT.

DESIGN

We used a Delphi approach, which allows for generation of consensus.

PARTICIPANTS

Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups.

MAIN MEASURES

The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty.

KEY RESULTS

Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches.

CONCLUSIONS

This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.

Tailoring the physical properties of the mixtures of ionic liquids: a microscopic point of view

A detailed investigation of the phase diagram of the mixtures of the two ionic liquids N-trimethyl-N-propylammonium bis(trifluoromethylsulfonyl)imide (TMPA-TFSI) and N-trimethyl-N-hexylammonium bis(trifluoromethylsulfonyl)imide (TMHA-TFSI) has been performed in the temperature range between 140 and 330 K by means of DSC and infrared spectroscopy measurements. In the low temperature crystalline states, a large concentration of the trans-TFSI conformer is present in TMPA-TFSI, while almost only cis-TFSI is retained in TMHA-TFSI. For the mixtures (TMPA-TFSI)_100-x (TMHA-TFSI)_x, at concentrations close to the extremes, solid crystalline phases are still present and they show a strong predominance of the trans conformer of the TFSI ion for x < 15 or a large concentration of the cis conformer of TFSI for x > 85. At intermediate concentrations (33 < x < 67) no crystalline phase develops at low temperatures and both conformers of TFSI survive in the whole temperature range investigated here. We suggest that the competition between the two TFSI conformers at low temperatures can be the origin of the lack of crystalline phases for intermediate concentrations and can be exploited as a valid tool to tailor the physical properties of the mixtures of ionic liquids.

J/ψ Elliptic Flow in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

We report a precise measurement of the J/ψ elliptic flow in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The J/ψ mesons are reconstructed at midrapidity (|y|<0.9) in the dielectron decay channel and at forward rapidity (2.5<y<4.0) in the dimuon channel, both down to zero transverse momentum. At forward rapidity, the elliptic flow v_{2} of the J/ψ is studied as a function of the transverse momentum and centrality. A positive v_{2} is observed in the transverse momentum range 2<p_{T}<8  GeV/c in the three centrality classes studied and confirms with higher statistics our earlier results at sqrt[s_{NN}]=2.76  TeV in semicentral collisions. At midrapidity, the J/ψ  v_{2} is investigated as a function of the transverse momentum in semicentral collisions and found to be in agreement with the measurements at forward rapidity. These results are compared to transport model calculations. The comparison supports the idea that at low p_{T} the elliptic flow of the J/ψ originates from the thermalization of charm quarks in the deconfined medium but suggests that additional mechanisms might be missing in the models.

A TNF-p100 pathway subverts noncanonical NF-κB signaling in inflamed secondary lymphoid organs

Lymphotoxin-beta receptor (LTβR) present on stromal cells engages the noncanonical NF-κB pathway to mediate RelB-dependent expressions of homeostatic chemokines, which direct steady-state ingress of naïve lymphocytes to secondary lymphoid organs (SLOs). In this pathway, NIK promotes partial proteolysis of p100 into p52 that induces nuclear translocation of the RelB NF-κB heterodimers. Microbial infections often deplete homeostatic chemokines; it is thought that infection-inflicted destruction of stromal cells results in the downregulation of these chemokines. Whether inflammation per se also regulates these processes remains unclear. We show that TNF accumulated upon non-infectious immunization of mice similarly downregulates the expressions of these chemokines and consequently diminishes the ingress of naïve lymphocytes in inflamed SLOs. Mechanistically, TNF inactivated NIK in LTβR-stimulated cells and induced the synthesis of Nfkb2 mRNA encoding p100; these together potently accumulated unprocessed p100, which attenuated the RelB activity as inhibitory IκBδ. Finally, a lack of p100 alleviated these TNF-mediated inhibitions in inflamed SLOs of immunized Nfkb2-/- mice. In sum, we reveal that an inhibitory TNF-p100 pathway modulates the adaptive compartment during immune responses.

Molecular epidemiology of goat pox viruses

Goat pox disease outbreaks were observed in different places affecting Black Bengal Goats in West Bengal (WB) and Tellicherry, Vembur and non-descriptive breeds in Tamil Nadu (TN) causing severe lesions and mortality up to 30%. Clinical specimens from all the outbreaks were screened by polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) and confirmed the diseases as Goat Pox. Virus isolation in Vero cell line was done with randomly selected ten samples, cytopathic effects (CPE) characterized by syncytia and intracytoplasmic inclusion bodies were observed after several blind passages. Nucleotide sequence of complete p32 gene using randomly selected two isolates and three clinical specimens revealed presence of Goat pox virus (GTPV)-specific signature residues in all the sequences. Phylogenetic analysis using the present five sequences along with GenBank data of GTPV complete p32 gene sequences showed all the GTPV sequences cluster together except Pellor strain (NC004003) and FZ Chinese strain (KC951854). The five sequences either from WB or TN cluster more closely with GTPV isolates of Maharashtra state that were responsible for cross species outbreak of pox disease in both sheep (KF468759) and goats (KF468762) in India during the year 2010. All the Indian goat pox viruses, including the Mukteswar strain, isolated in 1946 and sequence reported in 2004 clustered together with the GTPVs causing the recent outbreaks. It was observed that GTPVs caused similar clinical manifestation irrespective of their geographical locations and breed characteristics, no variation observed among the Indian isolates based on p32 gene over the period of seventy years and disease outbreaks could not be observed or reported in vaccinated goats.

Anomalous Evolution of the Near-Side Jet Peak Shape in Pb-Pb Collisions at sqrt[s_{NN}]=2.76 TeV

The measurement of two-particle angular correlations is a powerful tool to study jet quenching in a p_{T} region inaccessible by direct jet identification. In these measurements pseudorapidity (Δη) and azimuthal (Δφ) differences are used to extract the shape of the near-side peak formed by particles associated with a higher p_{T} trigger particle (1<p_{T,trig}<8  GeV/c). A combined fit of the near-side peak and long-range correlations is applied to the data allowing the extraction of the centrality evolution of the peak shape in Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV. A significant broadening of the peak in the Δη direction at low p_{T} is found from peripheral to central collisions, which vanishes above 4  GeV/c, while in the Δφ direction the peak is almost independent of centrality. For the 10% most central collisions and 1<p_{T,assoc}<2  GeV/c, 1<p_{T,trig}<3  GeV/c a novel feature is observed: a depletion develops around the center of the peak. The results are compared to pp collisions at the same center of mass energy and ampt model simulations. The comparison to the investigated models suggests that the broadening and the development of the depletion is connected to the strength of radial and longitudinal flow.

Spectroscopic evidence of a new energy scale for superconductivity in H3S

The discovery of a superconducting phase in sulfur hydride under high pressure with a critical temperature above 200 K has provided fresh impetus to the search for superconductors at ever higher temperatures. Although this systems displays all the hallmarks of superconductivity, the mechanism through which it arises remains to be determined. Here we provide a first optical spectroscopy study of this superconductor. Experimental results for the optical reflectivity of H₃S, under hydrostatic pressure of 150 GPa, for several temperatures and over the range 60 to 600 meV of photon energies, are compared with theoretical calculations based on Eliashberg theory. Two significant features stand out: some remarkably strong infrared active phonons at around 160 meV, and a band with a depressed reflectance in the superconducting state in the region from 450 meV to 600 meV. In this energy range H3S becomes more reflecting with increasing temperature, a change that is traced to superconductivity originating from the electron-phonon interaction. The shape, magnitude, and energy dependence of this band at 150 K agrees with our calculations. This provides strong evidence of a conventional mechanism. However, the unusually strong optical phonon suggests a contribution of electronic degrees of freedom.

Fatal peste des petits ruminants disease in Chowsingha

This communication reports fatal Peste des petits ruminants (PPR) disease in Chowsingha (Tetracerus quadricornis), a member of the subfamily Bovinae and family Bovidae captured in a Zoological Park. The animals showed clinical signs of acute respiratory disease with frothy nasal discharge (1-2 days) and mortality of twenty animals (80%) within 48 hr. Necropsy of dead Chowsingha showed haemorrhagic patches in trachea and severe congestion of lungs and ocular mucosa. There was no characteristic lesion in the intestine. Swabs from trachea and nasal tract along with tissue samples of spleen and lung from dead animals were found positive for PPR virus based on reverse transcription-polymerase chain reaction using H gene and partial N gene-specific primers. Sequence analysis of complete H gene and partial N gene confirmed the aetiological agent as PPR virus lineage IV. The identity of the Chowsingha tissues used for PPRV isolation was confirmed by the 12S ribosomal RNA gene sequencing, and the amplified gene was analysed identically to the Chowsingha mitochondrial 12S ribosomal RNA gene. The present information of PPR in Chowsingha is the first report of PPRV lineage IV causing cross-species fatal disease in subfamily bovinae and family Bovidae. The acute manifestation of the disease indicates high susceptibility of this vulnerable wild bovid species to PPR lineage IV. This report extends host range and demands enhanced surveillance among subfamily bovinae to strengthen PPR eradication programme.

Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment

BACKGROUND

Approximately 15% of hospitalized patients have an active substance use disorder (SUD). Starting treatment for SUD, including medications, during acute hospitalizations can engage patients in addiction care. In July 2015, the Boston Medical Center Addiction Consult Service (ACS), began providing inpatient diagnostic, management, and discharge linkage consultations. We describe this implementation.

METHODS

The ACS staff recorded SUDs diagnoses and medication recommendations and tracked follow-up data for affiliated outpatient office-based addiction clinics and methadone maintenance programs. We assessed the number of consults, SUDs diagnoses, medications recommended and initiated, and outpatient addiction clinic follow-up.

RESULTS

Over 26weeks, the BMC ACS completed 337 consults: 78% had an opioid use disorder (UD), 37% an alcohol UD, 28% a cocaine UD, 9% a benzodiazepine UD, 3% a cannabinoid (including K2) UD, and <1% a methamphetamine UD. Methadone was initiated in 70 inpatients and buprenorphine in 40 inpatients. Naltrexone was recommended 45 times (for opioid UD, alcohol UD, or both). Of the patients initiated on methadone, 76% linked to methadone clinic, with 54%, 39%, and 29% still retained at 30, 90, and 180days, respectively. For buprenorphine, 49% linked to clinic, with 39%, 27%, and 18% retained at 30, 90, and 180days, respectively. For naltrexone, 26% linked to clinic, all with alcohol UD alone.

CONCLUSIONS

A new inpatient addiction consultation service diagnosed and treated hospitalized patients with substance use disorders and linked them to outpatient addiction treatment care. Initiating addiction medications, particularly opioid agonists, was feasible in the inpatient setting. Optimal linkage and retention of hospitalized patients to post-discharge addiction care warrants further innovation and program development.

Current Trends of Using Antimicrobials and Their Sensitivity Pattern in Infectious Cases at Department of Orthopedics in a Tertiary Care Hospital

This cross-sectional descriptive study was carried out to analyse the current trends of using antimicrobials at orthopaedics department in different surgical procedures and observe the antimicrobial sensitivity pattern of infective organisms in postoperative wound infection cases at the department of Orthopaedics, Mymensingh Medical College Hospital with collaboration of department of Pharmacology and Therapeutics in Mymensingh Medical College, Mymensingh from January 2016 to December 2016. Among 253 orthopaedics surgical cases Penicillins, Cephalosporins, and Aminoglycoside group were commonly prescribed antimicrobials that had been use postoperatively in most of the Orthopaedics cases. Rate of occurring postoperative wound infection was 18.58%. Pseudomonas aeruginosa (36.17%) was the predominant microorganisms in our study followed by Klebsiellae (12.77%), Proteus (10.64%), Escherichia coli and (6.38%) Enterococcus (4.25%). Pseudomonas aeruginosa exhibited sensitivities to Gentamicin (35.29%), Amikacin (35.29%). Good sensitivities patterns for Klebsiellae in our study were shown to Imipenam (100%), Gentamicin (20%). Sensitivity patterns for Proteus in our study were shown to Imipenam (80%), Gentamicin (20%). Enterococcus in our study showed good sensitivities against Imipenam (100%), Linezolid (100%). Cephalosporin generation showed more resistance.