Military Veterans' Perspectives on Postoperative Opioid Use: A Secondary Analysis of Qualitative Data

PURPOSE

This qualitative analysis of interviews with surgical patients who received a brief perioperative psychological intervention, in conjunction with standard medical perioperative care, elucidates patient perspectives on the use of pain self-management skills in relation to postoperative analgesics.

DESIGN

This study is a secondary analysis of qualitative data from a randomized controlled trial.

METHODS

Participants (N = 21) were rural-dwelling United States Military Veterans from a mixed surgical sample who were randomized to receive a manual-based, telephone-based Perioperative Pain Self-management intervention consisting of a total of four pre- and postoperative contacts. Semi-structured qualitative interviews elicited participant feedback on the cognitive-behavioral intervention. Data was analyzed by two qualitative experts using MAXQDA software. Key word analyses focused on mention of analgesics in interviews.

FINDINGS

Interviews revealed a dominant theme of ambivalence towards postoperative use of opioids. An additional theme concerned the varied ways acquiring pain self-management skills impacted postoperative opioid (and non-opioid analgesic) consumption. Participants reported that employment of pain self-management strategies reduced reliance on pharmacology for pain relief, prolonged the time between doses, took the "edge off" pain, and increased pain management self-efficacy.

CONCLUSIONS

Perioperative patient education may benefit from inclusion of teaching non-pharmacologic pain self-management skills and collaborative planning with patients regarding how to use these skills in conjunction with opioid and non-opioid analgesics. Perianesthesia nurses may be in a critical position to provide interdisciplinary postoperative patient education that may optimize postoperative pain management while minimizing risks associated with prolonged opioid use.

ERPs reveal an iconic relation between sublexical phonology and affective meaning

Classical linguistic theory assumes that formal aspects, like sound, are not internally related to the meaning of words. However, recent research suggests language might code affective meaning such as threat and alert sublexically. Positing affective phonological iconicity as a systematic organization principle of the German lexicon, we calculated sublexical affective values for sub-syllabic phonological word segments from a large-scale affective lexical German database by averaging valence and arousal ratings of all words any phonological segment appears in. We tested word stimuli with either consistent or inconsistent mappings between lexical affective meaning and sublexical affective values (negative-valence/high-arousal vs. neutral-valence/low-arousal) in an EEG visual-lexical-decision task. A mismatch between sublexical and lexical affective values elicited an increased N400 response. These results reveal that systematic affective phonological iconicity - extracted from the lexicon - impacts the extraction of lexical word meaning during reading.

Enhancing the Biopsychosocial Approach to Perioperative Care: A Pilot Randomized Trial of the Perioperative Pain Self-management (PePS) Intervention

OBJECTIVE

The current study aimed to pilot the PePS intervention, based on principles of cognitive behavioral therapy (CBT), to determine feasibility and preliminary efficacy for preventing chronic pain and long-term opioid use.

SUMMARY BACKGROUND DATA

Surgery can precipitate the development of both chronic pain and long-term opioid use. CBT can reduce distress and improve functioning among patients with chronic pain. Adapting CBT to target acute pain management in the postoperative period may impact longer-term postoperative outcomes.

METHODS

This was a mixed-methods randomized controlled trial in a mixed surgical sample with assignment to standard care or PePS, with primary outcomes at 3-months postsurgery. The sample consisted of rural-dwelling United States Military Veterans.

RESULTS

Logistic regression analyses found a significant effect of PePS on odds of moderate-severe pain (on average over the last week) at 3-months postsurgery, controlling for preoperative moderate-severe pain: Adjusted odds ratio = 0.25 (95% CI: 0.07-0.95, P < 0.05). At 3-months postsurgery, 15% (6/39) of standard care participants and 2% (1/45) of PePS participants used opioids in the prior seven days: Adjusted Odds ratio = 0.10 (95% CI: 0.01-1.29, P = .08). Changes in depression, anxiety, and pain catastrophizing were not significantly different between arms.

CONCLUSIONS

The findings from this study support the feasibility and preliminary efficacy of the PePS intervention.

The Impact of Preoperative Distress: A Qualitative analysis of the Perioperative Pain Self-Management Intervention

PURPOSE

Preoperatively distressed patients are at elevated risk for chronic postsurgical pain. Active psychological interventions show promise for mitigating chronic postsurgical pain. This study describes experiences of preoperatively distressed (elevated depressive symptom, anxious symptoms, or pain catastrophizing) and non-distressed participants who participated in the psychologically based Perioperative Pain Self-management (PePS) intervention.

DESIGN

This is a qualitative study designed to capture participants' perspectives and feedback about their experiences during the PePS intervention.

METHODS

Interviews were semi-structured, conducted by telephone, audio-recorded, transcribed, and audited for accuracy. Coded interviews were analyzed using a quote matrix to discern possible qualitative differences in what preoperatively distressed and non-distressed participants found most and least helpful about the intervention.

RESULTS

Twenty-one participants completed interviews, 7 of whom were classified as distressed. Distressed participants identified learning how to reframe their pain as the most helpful part of the intervention. Non-distressed participants focused on the benefit of relaxation skill-building to manage post-surgical pain. Distressed and non-distressed participants both emphasized the importance of the social support aspects of PePS and- identified goal-setting as challenging.

CONCLUSIONS

Distressed and non-distressed participants emphasized different preferences for pain management strategies offered by PePS. Most participants emphasized the importance of social support that PePS provided.

CLINICAL IMPLICATIONS

Our results indicate that post-operative patients may benefit from interpersonal interaction with a trained interventionist. Our findings also suggest that distressed and non-distressed patients may benefit from varied intervention approaches. How to build flexibility into a manualized intervention or whether these subsets of patients would benefit more from different interventions is a direction for future research.

Adverse events during nursing care procedure in intensive care unit: The PREVENIR study

OBJECTIVES

Intensive care unit patients undergo several nursing care procedures (NCP) every day. These procedures involve a risk for adverse events (AE). Yet, their prevalence, intensity, and predisposing risk factors remain poorly established. The main objective of the study was to measure the incidence and severity of NCP related AE.

DESIGN

This prospective observational multicentre study was conducted in 9 ICUs. All NCP were recorded for four consecutive weeks. For each NCP, the following were collected: patients' baseline characteristics, type of NCP, characteristics of the NCP, AE and therapeutic responses.

RESULTS

5849 NCP occurred in 340 patients. Among the 340 patients included, 292 (85.9%) were affected by at least one AE, and 141 (41.5%) by an SAE during a NCP. Thirty % of NCP were associated with at least one AE: hemodynamic AE in 17.1%, respiratory AE in 13.6%, agitation and pain (3.7% and 3.3%). Eight invasive devices were accidentally removed. Severe Adverse Events (SAE) occurred in 5.5% of NCP. The main risk factor associated with SAE was pain/agitation at the beginning of the NCP.

CONCLUSION

AE are frequent during NCP in ICU. We identified several risk factors, some of them preventable, that could be considered for the development of recommendations for the nursing care of critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02881645.

Revealing interfacial disorder at the growth-front of thick many-layer epitaxial graphene on SiC: a complementary neutron and X-ray scattering investigation

Epitaxial graphene on SiC provides both an excellent source of high-quality graphene as well as an architecture to support its application. Although single-layer graphene on Si-face SiC has garnered extensive interest, many-layer graphene produced on C-face SiC could be significantly more robust for enabling applications. Little is known, however, about the structural properties related to the growth evolution at the buried interface for thick many-layer graphene. Using complementary X-ray scattering and neutron reflectivity as well as electron microscopy, we demonstrate that thick many-layer epitaxial graphene exhibits two vastly different length-scales of the buried interface roughness as a consequence of the Si sublimation that produces the graphene. Over long lateral length-scales the roughness is extremely large (hundreds of Å) and it varies proportionally to the number of graphene layers. In contrast, over much shorter lateral length-scales we observe an atomically abrupt interface with SiC terraces. Graphene near the buried interface exhibits a slightly expanded interlayer spacing (∼1%) and fluctuations of this spacing, indicating a tendency for disorder near the growth front. Nevertheless, Dirac cones are observed from the graphene while its domain size routinely reaches micron length-scales, indicating the persistence of high-quality graphene beginning just a short distance away from the buried interface. Discovering and reconciling the different length-scales of roughness by reflectivity was complicated by strong diffuse scattering and we provide a detailed discussion of how these difficulties were resolved. The insight from this analysis will be useful for other highly rough interfaces among broad classes of thin-film materials.

Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: a multicenter cohort study

PURPOSE

We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission.

METHODS

We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3-6 (indicating moderate-to-severe disability or death) on the modified Rankin scale.

RESULTS

Overall, 259 patients with a score on the Glasgow coma scale of 9 (6-12) and a body temperature of 38.7 (38.1-39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18-4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21-4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35-6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28-0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results.

CONCLUSIONS

In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.

Quantitative thyroid scintigraphy for the differentiation of Graves’ disease and hyperthyroid autoimmune thyroiditis

Aim: The TCTUs (global 99mTc-pertechnetate thyroid uptake under suppression) can be used as an estimate of the iodine clearance of non-TSH regulated tissue. High TCTUs levels are characteristic for Graves’ disease (GD). Decreased uptake has been described in autoimmune thyroiditis (AIT). However, systematically investigated data in a larger series of AIT-patients with subclinical or overt hyperthyroidism are not published so far. The purpose of this study is the evaluation of the TCTUs in the differentiation between AIT and GD in patients with hyperthyroidism. Methods: We determined the TCTUs in 59 patients with untreated hyperthyroid GD and in 51 patients with AIT who had subclinical or manifest hyperthyroidism without medication. Patients with GD were characterized by the presence of hyperthyroidism, decreased echogenicity of the thyroid, elevation of TSH-receptor autoantibodies (TRAb). AIT was defined by a decreased echogenicity of the thyroid, absence of elevated TSH-receptor autoantibodies (TRAb), autoantibodies against the thyroid peroxidase (anti-TPO) and spontaneous remission or development of subclinical hypothyroidism within 3 months. Results: Thyroid volumes of patients with AIT were significantly lower than those of patients with GD (p <0.05). TRAb levels were significantly higher in GD-patients (median: 19.5 U/ml; range: 15.3-35 U/ml) than in AIT-patients (median: 1.3 U/ml; range: 0-4.1 U/ml). 73% (38/59) of patients with GD had elevated anti-TPO levels. In these patients anti-TPO levels (median: 768 U/l; range: 83-6397 U/l) were not significantly different from anti-TPO levels of patients with AIT (median: 834 U/l; range: 107-8675 U/l; p = 0.17). TCTUs values of patients with AIT were significantly lower (p <0.05; median: 0.9%; range: 0.1-3.2%) than those of patients with GD (median: 5.7%; range: 1.9-28.3%). Conclusion: In our patients quantitative thyroid scintigraphy with 99mTcO4 - offered rapid and reliable differentiation between hyperthyroid GD and AIT.

Development of the Classism Attitudinal Profile (CAP)

Despite increasing interest in social class issues within psychology, there are a limited number of theoretically rooted instruments to measure subjective social class, particularly related to classism. The purpose of this project was to create a brief, psychometrically sound, and theoretically grounded instrument, called the Classism Attitudinal Profile (CAP), designed to measure 2 aspects of classism (downward and upward) defined in Liu's (2011) Social Class World View Model Revised (SCWM-R). Data from 2 independent samples (n = 608, n = 199) provided evidence in support of the consistency (alpha and test-retest coefficients), anticipated factor structure, and convergent/discriminant validity of CAP subscale scores. Downward and upward classism scores were only modestly correlated with each other and differentially correlated with other measures, thereby demonstrating that CAP subscales measure distinct constructs rather than opposite ends of the same continuum. Validity of CAP scores was further supported by logically consistent patterns of relationships with measures of subjective social status, materialistic values, Protestant work ethic, life satisfaction, racism, sexism, and key demographic variables. (PsycINFO Database Record

History of the Concept of Addiction

Our distant forebears wrestled with concepts of alcohol addiction not unlike those of today: Is addiction a sin or a disease? Is addiction caused by the gods, the substance, the individual's vulnerability, or psychological or social factors? Luther, Calvin, and Catholic Church leaders viewed moderate alcohol use as God's gift; used intemperately, it was a moral transgression. The founders of modern scientific psychiatry rejected moral explanations for addiction in favor of an early biological model. The first two versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I and DSM-II) stigmatized addiction by listing it with other societally disapproved disorders stemming from personality disorder. DSM-III espoused atheoretical, descriptive diagnoses but required tolerance or withdrawal to diagnose dependence. Substance dependence in DSM-III-R included physiological and behavioral symptoms and reflected the substance dependence syndrome. DSM-IV's emphasis on biology in its concept of dependence was unchanged from its immediate predecessors. DSM-5 declared that all drugs taken in excess have in common the direct activation of the brain reward system. This article examines evolving concepts of alcohol addiction through 12,000 years of recorded human history, from the first mention of alcohol consumption in China more than 12,000 years ago to alcohol use and abuse in the DSM era, 1952 to the present.

Semiconducting Graphene from Highly Ordered Substrate Interactions

While numerous methods have been proposed to produce semiconducting graphene, a significant band gap has never been demonstrated. The reason is that, regardless of the theoretical gap formation mechanism, subnanometer disorder prevents the required symmetry breaking necessary to make graphene semiconducting. In this work, we show for the first time that semiconducting graphene can be made by epitaxial growth. Using improved growth methods, we show by direct band measurements that a band gap greater than 0.5 eV can be produced in the first graphene layer grown on the SiC(0001) surface. This work demonstrates that order, a property that remains lacking in other graphene systems, is key to producing electronically viable semiconducting graphene.

Induction of inducible nitric oxide synthase (iNOS) expression by oxLDL inhibits macrophage derived foam cell migration

OBJECTIVE

Deletion of inducible nitric oxide synthase (iNOS) in apolipoprotein E knockout mice was shown to mitigate the extent of arteriosclerosis. Oxidized low density lipoprotein (oxLDL) inhibits macrophage migration and traps foam cells, possibly through a mechanism involving oxidative stress. Here, we addressed whether a reduction of iNOS-mediated oxidative stress remobilizes macrophage-derived foam cells and may reverse plaque formation.

METHODS

Migration of RAW264.7 cells and bone marrow cells was quantified using a modified Boyden chamber. iNOS expression, phalloidin staining, focal adhesion kinase phosphorylation, lipid peroxides, nitric oxide (NO) and reactive oxygen species (ROS) production were assessed.

RESULTS

oxLDL treatment significantly reduced cell migration compared to unstimulated cells (p < 0.05). This migratory arrest was reversed by co-incubation with a pharmacologic iNOS inhibitor 1400 W (p < 0.05) and iNOS-siRNA (p > 0.05). Furthermore, apoE/iNOS double knockout macrophages do not show migratory arrest in response to oxLDL uptake, compared to apoE knockout controls (p > 0.05). We documented significantly increased iNOS expression following oxLDL treatment and downregulation using 1400 W and small inhibitory RNA (siRNA). iNOS inhibition was associated with a reduction in NO and peroxynitrite (ONOO-)- and increased superoxide generation. Trolox treatment of RAW264.7 cells restored migration indicating that peroxynitrite mediated lipid peroxide formation is involved in the signaling pathway mediating cell arrest..

CONCLUSIONS

Here, we provide pharmacologic and genetic evidence that oxLDL induced iNOS expression inhibits macrophage-derived foam cell migration. Therefore, reduction of peroxynitrite and possibly lipid hydroperoxide levels in plaques represents a valuable therapeutic approach to reverse migratory arrest of macrophage-derived foam cells and to impair plaque formation.

[The first 24 hours: acute dyspnea]

Acute dyspnea is a common presentation in the emergency department. Immediate diagnostic strategy and efficient management is crucial. Therefore, a diagnostic work up consisting of a brief medical history, physical examination and technical investigations, including laboratory tests, is presented. Identification of the cardio-vascular, pulmonary or other etiology enables the initiation of adequate therapy. This is outlined in detail for three common entities.

Allergic diseases, gene-environment interactions

Allergic asthma develops in part from dysregulation of the innate and adaptive immune functions, particularly an imbalance in the Th2-driven adaptive immune response. This dysregulation is the result of complex interactions between genes and environment. These interactions occur both pre- and postnatally, providing opportunities for early interventions in immunological programming.

Mathematical Identification of a Neuronal Network Consisting of GABA and DA in Striatal Slices of the Rat Brain

High frequency stimulation (HFS) has been used to treat various neurological and psychiatric diseases. Although further disorders are under investigation to extend the clinical application of HFS, the complex effect of HFS within a neuronal network is still unknown. Thus, it would be desirable to find a theoretical model that allows an estimation of the expected effect of applied HFS. Based on the neurochemical analysis of effects of the γ-aminobutyric acid (GABA)Areceptor antagonist bicuculline, the D2-like receptor antagonist sulpiride and the D1-like receptor antagonist SCH-23390 on HFS evoked GABA and dopamine (DA) release from striatal slices of the rat brain, a mathematical network model is proposed including the neurotransmitters GABA, DA and glutamate (GLU). The model reflects inhibitory and excitatory interactions of the neurotransmitters outflow in the presence of HFS. Under the assumption of linear interactions and static measurements, the model is expressed analytically. Numerical identification of inhibition and excitation is performed on a basis of real outflow levels of GABA and DA in the rat striatum. Results validate the nature of the proposed model. Therefore, this leads to an analytical model of the interactions within distinct neural network components of the rat striatum.

The cystine/cysteine cycle: a redox cycle regulating susceptibility versus resistance to cell death

The glutathione-dependent system is one of the key systems regulating cellular redox balance, and thus cell fate. Cysteine, typically present in its oxidized form cystine in the extracellular space, is regarded as the rate-limiting substrate for glutathione (GSH) synthesis. Cystine is transported into cells by the highly specific amino-acid antiporter system xc-. Since Burkitt's Lymphoma (BL) cells display limited uptake capacity for cystine, and are thus prone to oxidative stress-induced cell death, we stably expressed the substrate-specific subunit of system xc-, xCT, in HH514 BL cells. xCT-overexpressing cells became highly resistant to oxidative stress, particularly upon GSH depletion. Contrary to previous predictions, the increase of intracellular cysteine did not affect the cellular GSH pool, but concomitantly boosted extracellular cysteine concentrations. Even though cells were depleted of bulk GSH, xCT overexpression maintained cellular integrity by protecting against lipid peroxidation, a very early event in cell death progression. Our results show that system xc- protects against oxidative stress not by elevating intracellular GSH levels, but rather creates a reducing extracellular environment by driving a highly efficient cystine/cysteine redox cycle. Our findings show that the cystine/cysteine redox cycle by itself must be viewed as a discrete major regulator of cell survival.

The principle of homeostasis in the hypothalamus-pituitary-adrenal system: new insight from positive feedback

Feedback control, both negative and positive, is a fundamental feature of biological systems. Some of these systems strive to achieve a state of equilibrium or “homeostasis”. The major endocrine systems are regulated by negative feedback, a process believed to maintain hormonal levels within a relatively narrow range. Positive feedback is often thought to have a destabilizing effect. Here, we present a “principle of homeostasis,” which makes use of both positive and negative feedback loops. To test the hypothesis that this homeostatic concept is valid for the regulation of cortisol, we assessed experimental data in humans with different conditions (gender, obesity, endocrine disorders, medication) and analyzed these data by a novel computational approach. We showed that all obtained data sets were in agreement with the presented concept of homeostasis in the hypothalamus-pituitary-adrenal axis. According to this concept, a homeostatic system can stabilize itself with the help of a positive feedback loop. The brain mineralocorticoid and glucocorticoid receptors—with their known characteristics—fulfill the key functions in the homeostatic concept: binding cortisol with high and low affinities, acting in opposing manners, and mediating feedback effects on cortisol. This study supports the interaction between positive and negative feedback loops in the hypothalamus-pituitary-adrenal system and in this way sheds new light on the function of dual receptor regulation. Current knowledge suggests that this principle of homeostasis could also apply to other biological systems.