Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar)

AIM

Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP).

METHOD

Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests.

RESULTS

SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001.

CONCLUSION

The SEWS is the superior measure of AWS symptoms.

Single-dose intravenous ketamine or intramuscular naltrexone for high-utilization inpatients with alcohol use disorder: pilot trial feasibility and readmission rates

BACKGROUND

Alcohol use disorder (AUD) accounts for millions of acute care encounters annually in the United States. Hospitalization represents a vital opportunity to intervene pharmacologically, but low medication adherence is a significant barrier. Two single-dose, adherence-independent interventions are well suited for pre-discharge administration: intravenous (IV) ketamine and intramuscular (IM) naltrexone. Their feasibility and readmission-reducing efficacy in hospital settings are not well-established.

METHODS

A 3-arm, open-label randomized trial was conducted at our safety-net medical hospital among high-utilization inpatients with severe AUD. Consented adults (age 18-65) were randomized to (1) IV ketamine (KET) 0.5 mg/kg over 40 min, (2) IM naltrexone (NTX) 380 mg once, or (3) linkage alone (LA). The primary clinical outcome was 30-day all-cause hospital readmission rate. All were provided enhanced linkage to outpatient addiction clinic.

RESULTS

We consented and randomized 44 participants (n = 13, 14, 17 for KET, NTX, LA, respectively), with a mean of 3.2 past-year hospitalizations. Compared to the LA arm, both the KET arm (RR 0.37, p = 0.17) and NTX arm (RR 0.52, p = 0.27) had a lower 30-day readmission rate, though the differences were nonsignificant. Immediate acceptability ratings of KET and NTX were 9.50 and 9.17 out of 10, respectively. No serious adverse events or illicit ketamine use was reported.

CONCLUSIONS

Both interventions are feasible and showed promise in reducing readmissions for high-utilization AUD inpatients. Despite randomization, baseline characteristics may have differed in ways that biased against the control arm. Additional pragmatic studies-with larger sample size, blinding, and robust follow-up data collection-are needed to verify findings and better understand mediating factors.

CLINICALTRIALS

gov Identifier NCT04562779. Registered 24 September 2020. https://clinicaltrials.gov/ct2/show/NCT04562779.

Estimating costs of hospitalizations associated with opioid use disorder or opioid misuse at a large, urban safety-net hospital-Denver, Colorado, 2017

INTRODUCTION

The national and state economic burden of the opioid crisis is substantial. This study estimated the number of hospitalizations associated with opioid use disorder (OUD) or opioid misuse (OM) and the cost of those hospitalizations at Denver Health (DH) Medical Center, a large, urban safety-net hospital.

METHODS

For 2017, direct inpatient medical costs for hospitalizations associated with OUD or OM at DH Medical Center were estimated and categorized by group and insurance type. Data were from the DH electronic health records database that included charge data. Hospitalizations associated with OUD or OM were identified using diagnostic codes and an expanded set of inclusion criteria including diagnostic codes, opioid withdrawal assessments, opioid-related admission notes, and medication prescriptions to treat OUD. Costs were estimated using cost-to-charge ratios specific to DH.

RESULTS

During 2017, 220 hospitalizations, $9,834,979 in total charges, $3,690,724 in estimated total costs, and $2,115,990 in total reimbursements were identified using diagnostic codes. Using the most expansive set of inclusion criteria, 739 hospitalizations, $35,033,157 in total charges, $13,346,099 in estimated total costs, and $7,020,877 in total reimbursements were identified. Of the 739 hospitalizations, Medicaid covered 546 hospitalizations (74 %), the largest proportion of total reimbursement (65 %), with estimated total costs of $10,135,048 (77 %).

CONCLUSIONS

Our study identified considerable costs for hospitalizations associated with OUD or OM for DH. Estimating costs for hospitalizations associated with OUD or OM through use of expanded inclusion methodology can guide future program planning to allocate resources efficiently for hospitals such as DH Medical Center.

Accomplishing much in a short time: use of a rapid improvement event to redesign the assessment and treatment of patients with alcohol withdrawal

The use of Lean tools for quality improvement and process refinement is gaining acceptance in many health care institutions. Traditionally, these tools are used to apply incremental changes to established processes in order to reduce waste and improve quality. In this article, the authors describe a novel Lean methodology, the Rapid Improvement Event (RIE), used in a unique way to develop a new treatment protocol for a specific medical condition: alcohol withdrawal. The RIE allowed for the collaboration of a multidisciplinary group of providers invested in the success of a new protocol for alcohol withdrawal that spans areas from the emergency department to the inpatient ward at an inner-city safety net hospital. It also allowed for the definition of measures for its success once it is implemented.

A cytosolic catalase is needed to extend adult lifespan in C. elegans daf-C and clk-1 mutants

The dauer larva is an alternative larval stage in Caenorhabditis elegans which allows animals to survive through periods of low food availability. Well-fed worms live for about three weeks, but dauer larvae can live for at least two months without affecting post-dauer lifespan. Mutations in daf-2 and age-1, which produce a dauer constitutive (Daf-C) phenotype, and in clk-1, which are believed to slow metabolism, markedly increase adult lifespan. Here we show that a ctl-1 mutation reduces adult lifespan in otherwise wild-type animals and eliminates the daf-c and clk-1-mediated extension of adult lifespan. ctl-1 encodes an unusual cytosolic catalase; a second gene, ctl-2, encodes a peroxisomal catalase. ctl-1 messenger RNA is increased in dauer larvae and adults with the daf-c mutations. We suggest that the ctl-1 catalase is needed during periods of starvation, as in the dauer larva, and that its misexpression in daf-c and clk-1 adults extends lifespan. Cytosolic catalase may have evolved to protect nematodes from oxidative damage produced during prolonged dormancy before reproductive maturity, or it may represent a general mechanism for permitting organisms to cope with the metabolic changes that accompany starvation.

Beauty mandates and the appearance obsession

ABSTRACT This article examines the effects of appearance norms within lesbian communities, drawing both on the research literature and on direct interviews with lesbian and bisexual women. In particular, the authors assess the impact of heterosexual beauty mandates on women's communities and ask whether lesbian and bisexual women are affected by the dominant culture's beauty mandates to a similar or lesser degree than heterosexual women. In addition, the authors examine appearance mandates developed by women within lesbian subculture. The positive and negative effects of these various "styles" on members of different lesbian subcultures are discussed.

Bisexual women and beauty norms

ABSTRACT This article examines how coming out and gender of partner affect bisexual women's behavior, thoughts and feelings regarding beauty and appearance norms. Seventy-four bisexual women participated in a qualitative survey addressing these issues. Results showed that just under half (49%) of respondents felt that coming out as bisexual affected their beauty ideas and practices and over two-thirds (71%) felt that the gender of their partners affected their beauty ideas and practices. Most of the latter group (80%) felt more appearance pressures when involved with men than when involved with women. Themes from open-ended responses are presented through specific examples and the implications of findings are discussed.

Risk of juvenile justice systems referral among children in a public mental health system

This study established the risk of police referral among a cohort of children who were recipients of public mental health services. Investigators used secondary data to calculate the incidence of criminal referral among 645 children, ages 10 to 17, who entered community-based public mental health programs in King County, Washington. Children receiving public mental health services were nearly three times more likely to be referred to the juvenile justice system compared to children of similar age and gender in the general population. Relative risks were particularly high for younger children (10-13 years) and for children of Hispanic, Native American, and Caucasian origin. Understanding the characteristics and experiences of children who use multiple-service systems has important implications for services delivery. In addressing the needs of youth who have both mental illness and criminal involvement, age- and culturally specific interventions and advocacy efforts are warranted.

Efficient self-assembly of human papillomavirus type 16 L1 and L1-L2 into virus-like particles

The L1 genes of two human papillomavirus type 16 (HPV16) isolates derived from condylomata acuminata were used to express the L1 major capsid protein in insect cells via recombinant baculoviruses. Both L1 major capsid proteins self-assembled into virus-like particles (VLP) with high efficiency and could be purified in preparative amounts on density gradients. The yield of VLP was 3 orders of magnitude higher than what has been obtained previously, using L1 derived from the prototype HPV16. DNA sequence comparison identified a single nonconserved amino acid change to be responsible for the inefficient self-assembly of the prototype L1. VLP were also obtained by expressing L1 of HPV6, HPV11, and cottontail rabbit papillomavirus, indicating that L1 from a variety of papillomaviruses has the intrinsic capacity to self-assemble into VLP. Coexpression of HPV16 L1 plus L2 by using a baculovirus double-expression vector also resulted in efficient self-assembly of VLP, and the average particle yield increased about fourfold in comparison to when L1 only was expressed. Coimmunoprecipitation of L1 and L2 and cosedimentation of the two proteins in a sucrose gradient demonstrated that L2 was incorporated into the particles. The ability to generate preparative amounts of HPV16 L1 and L1-L2 VLP may have implications for the development of a serological assay to detect anti-HPV16 virion immune responses to conformational epitopes and for immunoprophylaxis against HPV16 infection.

Myocardial preservation using lidocaine blood cardioplegia

Prevention of ventricular fibrillation after aortic unclamping using lidocaine hydrochloride as an additive to cold potassium blood cardioplegia was studied prospectively in 46 patients undergoing elective myocardial revascularization. Patients were similar with respect to age, ventricular function, severity of coronary artery disease, cross-clamp time, completeness of revascularization, frequency of internal thoracic artery grafting, systemic temperature at the time of cross-clamp removal, and mean infusate volume and temperature. Patients receiving lidocaine blood cardioplegia (group 1, 23 patients) had a significant reduction in the incidence of ventricular fibrillation (22% versus 74%; p less than 0.0005) and in the mean number of cardioversion attempts required to defibrillate the heart (0.5 +/- 1.3 versus 1.9 +/- 0.97; p less than 0.0005) after cross-clamp removal compared with controls (group 2, 23 patients). There were no differences between the two groups postoperatively with regard to cardiac enzyme release, hemodynamic measurements, or clinical outcome. Patients receiving lidocaine blood cardioplegia tended to have a lower incidence of new postoperative atrial fibrillation (9% versus 26%). Ventricular function was preserved equally in both groups. We conclude that lidocaine is a safe additive to potassium blood cardioplegia and significantly reduces the incidence of ventricular fibrillation after aortic unclamping.

Biological activity of cloned rat endogenous C-type virus DNA transferred by microinjection

The biological activity of a molecularly cloned DNA of a rat endogenous C-type leukaemia helper virus, RHHV, was assessed by intranuclear microinjection into normal rat kidney cells (NRK153). Release of rat C-type leukaemia helper viruses by the microinjected cells was examined by superinfection of Kirsten-transformed non-producer cells (K-NRK). Immediate release of helper leukaemia viruses at a very low level was observed only in the NRK153 m3 . 5/cir cells microinjected with the supercoiled form of RHHV DNA in toto, suggesting that the circular form of the virus DNA might have expedited the replication and expression of virus particles. Genome rescue experiments were also performed by co-cultivating the microinjected NRK153 m cells carrying various linear RHHV DNAs, in toto or of subgenomic sizes, with K-NRK cells. The results indicated that both the total and the 5.8 to 6.2 kb DNA fragment proximal to the 5' terminus of the cloned RHHV 8.8 kb DNA were able to rescue successfully a transforming replication-competent pseudotype virus. Subgenomic DNA fragments derived from the centre or the 3' end of the RHHV DNA were ineffective in the genome rescue experiments.