bluuebunny/crossref_metadata_2025 huggingface dataset:
Pain and Addiction in Patients with Traumatic Brain Injury
Authors: Pangarkar Sanjog S.
Published: April 2018

Distinct from Chapter 24, on co-occurring psychiatric disorders, this chapter addresses common physical comorbidities that give rise to chronic pain and are notorious for associated substance use disorders. The concept of “pseudo-addiction” is explored as one of several contributors to common misperceptions of the analgesic needs of such patients. Examples of entities discussed are chronic low back pain, sleep apnea, chronic pancreatitis, cirrhosis, and HIV infection or AIDS-related pain. While not intrinsically painful, sleep apnea merits inclusion as it arises in conjunction with sedative-hypnotic, opioid, or nicotine use. Cirrhosis likewise creates obstacles to successful pain or addiction management resulting from altered metabolism of medications and enhanced susceptibility to potentially lethal syndromes (hepato-renal syndrome, gastric hemorrhage, etc.). The management of neuropathic pain in HIV infection (Chapter 15) is amplified here.
Pain and Addiction in Patients with Fibromyalgia
Authors: Muchowski Karen
Published: April 2018

The opening passages in this discussion of the interface between fibromyalgia, a chronic pain syndrome, and addiction describe background pathophysiology. Typical patients are discussed in terms of their historic and physical findings, leading to a review of the non-pharmacological and pharmacological managements available for this syndrome. While the diagnosis of fibromyalgia is commonly mischaracterized as attention-seeking behavior or feigned helplessness, many of the behaviors seen in fibromyalgia also are present in other, more accepted chronic disorders, from diabetes to HIV disease. Providing both an accepting manner and an assertive management approach toward the syndrome, the authors note significant improvement in patients who undergo aerobic exercise programs, as well as complementary and integrative medical strategies such as acupuncture, and meditative movement therapies such as yoga. Improvement in sleep patterns is commonly associated with overall symptom reduction.
Pain and Addiction in Women
Authors: Terplan Mishka
Published: April 2018

Women experience pain differently than men and suffer unique pain conditions. Pain syndromes frequently overlap in women and can be associated with co-occurring mental health disorders, addiction, and intimate partner violence as well as childhood sexual abuse. A discussion of extant concepts for understanding pain in women includes gender-role theory, exposure theory, and vulnerability theory. The chapter focuses predominantly on women of child-bearing age, and their unique risks and management requirements; consequently, contraceptive needs and fulfillment are reviewed for their place in the clinical management of pain and addiction. Unique to women, dysmenorrhea, chronic pelvic pain, endometriosis, fibromyalgia, interstitial cystitis, vulvodynia, and pregnancy may all be undervalued or overlooked in a non-gynecological setting. The higher susceptibility of women to osteoporotic disease and associated pain in older age constitutes another risk zone for pain mismanagement. A text box (30.1) describes the opioid neonatal abstinence syndrome, its diagnosis, and its management.
Psycho-Oncology Interventions and Programs for Sexual and Gender Minorities (DRAFT)
Authors: Bowen Deborah J. , Jabson Jennifer M. , Coughlin Steven S.
Published: April 2018

This chapter discusses the literature on cancer-related interventions for sexual and gender minority women and men and identifies directions for future research and practice. The authors divide the field up into interventions that operate in each of the four areas of cancer control: primary, secondary, tertiary, and quaternary prevention. The main interventions developed for primary prevention of cancer for sexual minority women and men involve tobacco reduction and obesity reduction. Interventions for preventing HIV infection in LGBT populations have informed more recent efforts to address cancer. A few interventions have been evaluated for secondary prevention of cancer, and a few interventions have targeted sexual minority women and men during the treatment period. We found no interventions on quaternary prevention in sexual and gender minority populations and no evaluated interventions to improve the cancer-related health of gender minority individuals. There are multiple directions for future research in this area.
Behavioral Health Emergencies (DRAFT)
Authors: Valpey Robin , Crawford-Faucher Amy
Published: April 2018

Behavioral health emergencies typically involve agitation with autonomic instability. Many medical and psychiatric conditions can precipitate agitation that could necessitate rapid response interventions. Non-pharmacologic therapies can be useful to modulate agitation or delirium, but the mainstay of pharmacologic treatment is either antipsychotics or benzodiazepines, depending on the underlying problem. Psychosis and delirium generally respond better to antipsychotics, while mania, catatonia, toxidromes, withdrawal, and agitation from head injuries are more effectively treated with benzodiazepines. Prompt recognition of severe alcohol withdrawal can improve mortality; getting a history of other drug use, including “designer drugs” can help inform care. This chapter discusses the treatment of agitation, catatonia, medication-related disturbances, and intoxication and withdrawal during emergencies.
The Emergency Crash Cart (DRAFT)
Authors: Martin-Cua Sarah
Published: April 2018

The emergency crash cart is one of the most important tools at the rapid response team’s (RRTs) disposal in a crisis situation. The crash cart contains a variety of items that are often necessary in a medical emergency. Careful consideration of contents and placement are necessary to ensure that the RRT has easy access to the crash cart. In order to ensure a standard of safety among all crash carts, various methods are used to monitor and maintain the crash carts. This chapter discusses the planning, procedures, and processes used to maintain the emergency crash cart ready for medical emergencies.

crash cart, emergency equipment, defibrillator, emergency medication, rapid response team (RRT), strategic planning
Dementia 1: Defining Dementia, Alzheimer’s Disease and Frontotemporal Dementia (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores dementia, and focuses on definitions of dementia, Alzheimer’s disease and Frontotemporal Dementia. Dementia is defined as a cognitive decline in one or more cognitive domains including memory, language, attention, visuospatial processing and social behavior. Two hallmark pathologic features of Alzheimer’s disease (AD) are plaques, which are formed from amyloid and neurofibrillary tangles, which involve tau, whereas symptoms of Frontotemporal Dementia (FTD) may include behavioral changes, apathy and disinhibition and ritualistic or repetitive behaviors. Language may also be affected, and this can be a presenting symptom.
Movement Disorders 2: Parkinson’s Plus and Degenerative Diseases (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores movement disorders, and focuses on Parkinson’s Plus and degenerative diseases. It outlines the features and pathology of dementia with lewy bodies (DLB), progressive supranuclear palsy (PSP), multiple systems atrophy (MSA) and corticobasal degeneration (CBD), as well as genetic movement disorders, Wilson’s disease, and Huntington’s disease.
Peripheral Nervous System 1: Neuropathy (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter explores the peripheral nervous system (PNS) and focuses on neuropathy. It outlines classifications of PNS injury (by process, etiology, distribution, affected fibers), examples of polyneuropathy, common mononeuropathies (carpal tunnel syndrome, ulnar neuropathy, radial neuropathy), and plexopathies (Erb Duchenne palsy, Klumpke’s palsy).
Neurologic Emergencies (DRAFT)
Authors: Kaplan Tamara , Milligan Tracey
Published: April 2018

The video in this chapter discusses neurologic emergencies, including the symptoms of increased intracranial pressure leading to herniation, subarachnoid haemorrhage (can be due to aneurysm, vascular malformation, or reversible cerebral vasoconstriction syndrome, and definition and management of status epilepticus.
Early Palliative Care for Patients with Advanced Cancer (DRAFT)
Authors: Hui David
Published: April 2018

This chapter discusses the Zimmermann trial, a large partially blinded, cluster randomized controlled trial of routine oncology care with or without early routine referral to palliative care. This landmark study found that early palliative care involvement was associated with improved quality of life, symptom burden and satisfaction among patients with advanced cancer. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case to illustrate some key points around palliative care referral.
Nurse-Led Palliative Care for Advanced Cancer Patients (DRAFT)
Authors: Martin Emily J. , Roeland Eric J.
Published: April 2018

This chapter summarizes the Bakitas et al. 2009 Project ENABLE II randomized controlled trial, which examined how a nurse-led palliative care intervention, provided concurrently with usual oncologic care, impacted quality of life, symptom intensity, mood, and resource use among advanced cancer patients. Longitudinal intention-to-treat analyses showed greater quality of life and less depressed mood in patients who received palliative care as compared with the control group. This chapter describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
Exercise for the Management of Cancer-Related Fatigue (DRAFT)
Authors: Flint Lynn A. , Widera Eric
Published: April 2018

The report described here is a systematic review and meta-analysis of 28 studies examining the relationship between physical exercise and cancer-related fatigue in adults with cancer. Overall, exercise was associated with improvements in cancer-related fatigue both during and after treatment. The data was most robust for patients with breast and prostate cancer. Aerobic exercise was the only specific type of exercise associated with an improvement in fatigue. Further study is needed to determine whether other types of exercise, such as resistance training and mind-body exercises like yoga, impact cancer-related fatigue. Further study would clarify whether exercise is associated with improvements in cancer-related fatigue for patients with malignancies other than breast or prostate cancer.
The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) (DRAFT)
Authors: Gray Nathan A. , LeBlanc Thomas W.
Published: April 2018

This chapter provides an overview and commentary on the SUPPORT trial main report, which began in 1989 and was published in 1995 and studied quality of care and communication in serious illness. It describes both the observational and interventional phases of this study, reviewing background and potential reasons for its negative findings. The chapter includes concise commentary on the study design and a brief review of relevant subsequent studies. Additionally, a short clinical case is included that highlights the impact of this study’s findings for similar interventions at the end-of-life and summarizes this large trial’s importance in forming a foundation for future study.
Association Between Advance Directives and Quality of End-of-Life Care (DRAFT)
Authors: Zhukovsky Donna S.
Published: April 2018

Advance care planning is a complex process whereby an individual reflects on future care options at the end of life after reflecting on his or her values and goals for care. These values, goals, and preferences are then communicated to key stakeholders in the process (i.e., proxy and surrogate decision-makers, family members, and health care providers). It is unclear how well the completion of advance directives and a written outcome of advance care planning affect desired patient outcomes. In this chapter, a critical review is provided of a mortality follow-back survey that evaluates the association of advance directives with quality of end-of-life care from the perspective of bereaved family members. Study strengths and limitations are described, as are directions for future research.
Outcomes Associated with End-of-Life Discussions (DRAFT)
Authors: Mori Masanori
Published: April 2018

Physicians and advanced cancer patients are often reluctant to talk about death. They frequently avoid end-of-life discussions (EOLds), although such conversations are essential to initiate advance care planning. In this prospective, a longitudinal multisite cohort study of advanced cancer patients and their informal caregivers, the authors suggested cascading benefits of EOLds between patients and their physicians. In total, 123 of 332 (37.0%) patients reported having EOLds with their physicians at baseline. EOLds were not associated with higher rates of emotional distress or psychiatric disorders. Instead, after propensity-score weighted adjustment, EOLds were associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care was associated with worse patient quality of life and worse bereavement adjustment. These findings may help destigmatize EOLds and assist physicians and patients in initiating such conversations and engaging in advance care planning.
Palliative Sedation Therapy and Survival (DRAFT)
Authors: Arthur Joseph
Published: April 2018

Patients with advanced illness sometimes experience severe and debilitating physical and psychological symptoms at the end of life that may be refractory to all kinds of conventional treatments available for symptom relief. In such situations, palliative sedation therapy (PST) may be indicated. However, its utilization has been subject to debate. One viewpoint is that PST may hasten death. However, some studies have indicated otherwise. This chapter discusses a multicenter, prospective, observational, nonrandomized population-based study that compared the overall survival of a cohort of terminally ill patients who received PST with a similar group of patients who did not. The study showed that PST does not shorten life when used to relieve refractory symptoms. The chapter also presents a clinical case scenario to illustrate who should receive PST.
Attitudes and Desires of Terminally Ill Patients Regarding Euthanasia and Physician-Assisted Suicide (DRAFT)
Authors: Kim Yu Jung
Published: April 2018

No studies have explicitly addressed the attitudes and desires of terminally ill patients on euthanasia and physician-assisted suicide (PAS). In this prospective cohort study, 988 terminally ill patients and 893 caregivers were surveyed. A total of 60.2% patients supported euthanasia or PAS in a standard poll question, but only 10.6% seriously considered these interventions for themselves. Patients with depressive symptoms, moderate to severe pain, and significant care needs were more likely to consider euthanasia and PAS. Half of the patients who initially considered euthanasia or PAS changed their minds at the follow-up interview, and an almost equal number newly considered these interventions. Patients with depressive symptoms and dyspnea were more likely to change their minds over time. According to the caregivers of 256 deceased patients, 5.6% of patients discussed euthanasia or PAS in the last month of life, 2.5% hoarded drugs for suicide, and 0.4% died by PAS.
Principles of Management in the Dynamic Healthcare Environment (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Today’s healthcare environment is dynamic with constantly growing demands, high complexity, high degree of uncertainty, fierce competition and is coping with new technologies and facing challenges from demanding patients. To survive in such an environment, managers should view the system globally, focus on the essentials, and use simple tools. This chapter discusses how to avoid suboptimization of systems, as the sum of local optima is not the system optimum. Similarly, this chapter introduces the practical notion of the satisficer’s approach that advocates for “good enough” solutions rather than the optimizer’s approach that always looks for perfect solutions. Finally, the chapter introduces the focused management approach that integrates concepts and tools such as the Lean approach, TOC, and the complete kit concept.
The Seven Focusing Steps of the Theory of Constraints (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

The theory of constraints has the potential to increase throughput significantly, using existing resources. It consists of seven focusing steps that, when applied, can create extra capacity in operating rooms, emergency departments, imaging services, labs, and so on. The seven steps are simple, intuitive, and easy to implement. This chapter discusses the first three steps of the theory of constraints: determining the system’s goal, establishing global performance measures, and identifying the system constraint. Tools are provided for identifying bottlenecks and determining measures of performance for the system. It also introduces the cost-utilization diagram that provides managers with a full-system view.
Implementation and the Process of Ongoing Improvement (DRAFT)
Authors: Ronen Boaz , Pliskin Joseph S , Pass Shimeon
Published: April 2018

Whereas the concepts and tools described in this book are intuitive, simple, and easy to understand, their implementation and the process of ongoing improvement are not trivial and require a great deal of management attention. The chapter describes the change-management process. It starts with a full business/functional diagnosis of the organization and goes through an implementation plan draft, training and knowledge transfer, and establishing value enhancement teams. Then, the organization should establish tools for monitoring and control and ensure sustainability through a process of ongoing improvement. The chapter also presents the 3–1–1 model for implementing changes in hospitals. As hospitals are highly complex organizations with multitudes of entities with many interactions among them, the 3–1–1 model guides managers where to focus their efforts. The process of ongoing improvement can use the “traffic lights” system for sustainability and continuous value creation.
Adjustment disorders in child and adolescent psychiatry (DRAFT)
Authors: Mulligan Aisling
Published: April 2018

The clinical description of adjustment disorder (AD) in children and young people is the same as in adults. However, the stressors or triggers to AD in childhood and adolescence may differ from those in adult life. Up to 30% of those presenting to acute psychiatric services for adolescents can be considered to have an AD. The diagnosis of AD is associated with an increased risk of suicide and of suicidal ideation in young people. While most young people recover from AD, the long-term prognosis of AD is different in young people than in adults—young people with AD have a higher risk of developing ongoing psychiatric illness than adults with AD.
Adjustment disorder: An occupational perspective (with particular focus on the military) (DRAFT)
Authors: Reid Geoffrey
Published: April 2018

Adjustment disorder is the most common psychiatric diagnosis in the armed forces, with a prevalence of 25–38% in those seen in the military psychiatric services, although PTSD has received far more attention in that setting. The military environment is characterized not just by the risk of exposure to major stressors during deployments, but also by a disciplined environment in which individuals lose some of their abilities to make choices regarding their environment or changes in their social milieu. It is also characterized by stoical attitudes that discourage displays of mental suffering. Young people, removed from the buffering effects of social support in their home environment, may not find alternative sources of confiding support readily available. Problem-solving and stress management strategies are the current main ingredients of management, and the condition carries a good prognosis for a return to work. However, there is a paucity of published research work.
Ethics in Palliative Care
Authors: Macauley Robert C.
Published: April 2018

No specialty faces more diverse and challenging ethical dilemmas than palliative medicine. What is the best way to plan ahead for the end of life? How should physicians respond when patients refuse treatments likely to be beneficial or demand treatments not likely to be? Who makes medical decisions for patients who are too ill to decide for themselves? Do patients have the “right to die” (and, if so, what exactly does that mean)? Other ethics texts have explored these issues but often from an academic perspective that overlooks the practical realities of clinical medicine. Conversely, medical textbooks frequently lack sufficient philosophical depth to fully explore the complexities of these issues. This complete guide to the ethics of palliative care combines clinical experience with philosophical rigor to provide a comprehensive analysis of this fascinating field. Using relevant case studies, core subjects such as intensive symptom management at the end of life, physician-assisted dying, and palliative sedation are examined from historical, legal, clinical, and ethical perspectives. Whereas pediatric issues are often an afterthought in palliative care textbooks, this guide explores the unique nature of ethical dilemmas in the prenatal, neonatal, and adolescent age groups. Other important topics such as neuro-palliative care, organ donation, research, and moral distress are also covered in detail. Written with clinical nuance for medical professionals—and clear language as well as a glossary for lay readers—this guide offers all readers an opportunity to explore and understand the fascinating ethical issues facing patients suffering from life-threatening illness.
Physician-Assisted Dying (DRAFT)
Authors: Macauley Robert C.
Published: April 2018

Physician-assisted dying (PAD) is now legal in several states, as well as some foreign countries. The primary arguments to justify the practice include autonomy, compassion, justice, non-abandonment, and transparency. Counterarguments include the wrongness of killing, the impact on the physician-patient relationship, potential exploitation of the vulnerable, and the slippery slope. While some oppose the practice on religious or purely moral grounds, a compelling public policy argument can be made against it without holding that every possible case of PAD is “immoral.” If the sole consideration is patient autonomy and relief of suffering, assisted dying could be offered without physician involvement,as is the case in some other countries. Without the imprimatur of the medical profession, however, PAD may not achieve the societal acceptance that advocates seek.
Black hole/pulsar binaries in the Galaxy
Authors: Shao Yong , Li Xiang-Dong
Published: April 2018

We have performed population synthesis calculation on the formation of binaries containing a black hole (BH) and a neutron star (NS) in the Galactic disc. Some of important input parameters, especially for the treatment of common envelope evolution, are updated in the calculation. We have discussed the uncertainties from the star formation rate of the Galaxy and the velocity distribution of NS kicks on the birthrate (${\sim } 0.6\hbox{--}13 \rm \, M\,yr^{-1}$) of BH/NS binaries. From incident BH/NS binaries, by modelling the orbital evolution due to gravitational wave radiation and the NS evolution as radio pulsars, we obtain the distributions of the observable parameters such as the orbital period, eccentricity, and pulse period of the BH/pulsar binaries. We estimate that there may be ∼3–80 BH/pulsar binaries in the Galactic disc and around 10 per cent of them could be detected by the Five-hundred-metre Aperture Spherical radio Telescope.
Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery
Authors: Babadjouni Robin , Wen Timothy , Donoho Daniel A , Buchanan Ian A , Cen Steven Y , Friedman Rick A , Amar Arun , Russin Jonathan J , Giannotta Steven L , Mack William J , Attenello Frank J
Published: April 2018

BACKGROUND

Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions.

OBJECTIVE

To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery.

METHODS

All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year.

RESULTS

We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea).

CONCLUSION

After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.
Microsurgical Resection of a Meningioma at the Entrance of Dorello's Canal Causing VI Cranial Nerve Compression: 2-Dimensional Operative Video
Authors: Alturki Abdulrahman , Enriquez-Marulanda Alejandro , Gupta Raghav , Thomas Ajith J , Ogilvy Christopher S
Published: April 2018

We describe the case of a 73-yr-old female patient with a 2-yr history of diplopia that has progressively become worse. Physical examination revealed a right VI cranial nerve (CN) palsy. Magnetic resonance imaging and angiography showed a dolichoectatic basilar artery near the VI CN. A suboccipital craniectomy was performed, initially with the intention to perform a microvascular decompression; however, a red mass was encountered at the entrance of the right Dorello's canal that was compressing the VI CN. Complete resection of the lesion was done and decompression of the nerve was accomplished. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.
Time-resolved spectroscopic observations of an M-dwarf flare star EV Lacertae during a flare
Authors: Honda Satoshi , Notsu Yuta , Namekata Kosuke , Notsu Shota , Maehara Hiroyuki , Ikuta Kai , Nogami Daisaku , Shibata Kazunari
Published: April 2018

We have performed five night spectroscopic observations of the Hα line of EV Lac with a medium wavelength resolution (R ∼ 10000) using the 2 m Nayuta telescope at the Nishi-Harima Astronomical Observatory. EV Lac always possesses the Hα emission line; however, its intensity was stronger on 2015 August 15 than during the other four night periods. On this night, we observed a rapid rise (∼20 min) and a subsequent slow decrease (∼1.5 hr) of the emission-line intensity of Hα, which was probably caused by a flare. We also found an asymmetrical change in the Hα line on the same night. The enhancement has been observed in the blue wing of the Hα line during each phase of this flare (from the flare start to the flare end), and absorption components were present in its red wing during the early and later phases of the flare. Such blue enhancement (blue asymmetry) of the Hα line is sometimes seen during solar flares, but only during the early phases. Even for solar flares, little is known about the origin of the blue asymmetry. Compared with solar flare models, the presented results can lead to better understanding of the dynamics of stellar flares.
Using essential oils to enhance nursing practice and for self-care
Authors: Allard Melissa E. , Katseres Julie
Published: April 2018

With the growing popularity of integrative medicine, essential oils have found their way back into healthcare. Essential oils provide a simple way to alleviate certain physical symptoms, promote emotional well-being, and provide comfort. This article discusses the administration and common uses of essential oils; their reported benefits, potential risks, and contraindications; and the current state of associated research.
Medical Marijuana Users are More Likely to Use Prescription Drugs Medically and Nonmedically
Authors: Caputi Theodore L. , Humphreys Keith
Published: April 2018

Objectives:

Previous studies have found a negative population-level correlation between medical marijuana availability in US states, and trends in medical and nonmedical prescription drug use. These studies have been interpreted as evidence that use of medical marijuana reduces medical and nonmedical prescription drug use. This study evaluates whether medical marijuana use is a risk or protective factor for medical and nonmedical prescription drug use.

Methods:

Simulations based upon logistic regression analyses of data from the 2015 National Survey on Drug Use and Health were used to compute associations between medical marijuana use, and medical and nonmedical prescription drug use. Adjusted risk ratios (RRs) were computed with controls added for age, sex, race, health status, family income, and living in a state with legalized medical marijuana.

Results:

Medical marijuana users were significantly more likely (RR 1.62, 95% confidence interval [CI] 1.50–1.74) to report medical use of prescription drugs in the past 12 months. Individuals who used medical marijuana were also significantly more likely to report nonmedical use in the past 12 months of any prescription drug (RR 2.12, 95% CI 1.67–2.62), with elevated risks for pain relievers (RR 1.95, 95% CI 1.41–2.62), stimulants (RR 1.86, 95% CI 1.09–3.02), and tranquilizers (RR 2.18, 95% CI 1.45–3.16).

Conclusions:

Our findings disconfirm the hypothesis that a population-level negative correlation between medical marijuana use and prescription drug harms occurs because medical marijuana users are less likely to use prescription drugs, either medically or nonmedically. Medical marijuana users should be a target population in efforts to combat nonmedical prescription drug use.
A Randomized, Placebo-controlled, Clinical Trial of Prazosin for the Treatment of Alcohol Use Disorder
Authors: Wilcox Claire E. , Tonigan J. Scott , Bogenschutz Michael P. , Clifford Joshua , Bigelow Rose , Simpson Tracy
Published: April 2018

Objectives:

The noradrenergic system plays an important role in the pathophysiology of alcohol use disorder (AUD). Medications in this class may reduce drinking. Our aims were to investigate this in a unique sample of individuals with AUD.

Methods:

Thirty-six individuals with AUD were randomized to treatment with prazosin, an alpha-1 noradrenergic antagonist, or placebo, for 6 weeks (target daily dose 16 mg). Hierarchical linear modeling was used to examine the effect of treatment group on rate of change in primary (drinks per week [DPW]) and several secondary outcome measures.

Results:

Prazosin did not significantly affect rate of reduction in alcohol use in the intent to treat sample (n = 36) compared with placebo, but did significantly increase the rate of reduction in DPW in an optimal treatment exposure subgroup (beta = −0.3; P = 0.01; event rate ratio 0.74; confidence interval 0.59, 0.93; n = 27). Poor adherence and tolerability may have contributed to null effects. Diastolic blood pressure (DBP) moderated the effects of treatment group on rate of reduction in drinks per drinking day, supporting previous work in doxazosin, another alpha-1 antagonist. Specifically, prazosin was associated with greater rates of reduction in drinking compared with placebo in individuals with high but not low DBP.

Conclusions:

Our findings do not support the clinical utility of prazosin for all treatment-seeking AUD, but post hoc analyses indicate that it might have some efficacy in individuals who can tolerate it. Further work exploring the clinical utility of DBP as a treatment matching variable, and defining optimal values using sensitivity and specificity analyses, is warranted.
Development and Validation of a Deep Neural Network Model for Prediction of Postoperative In-hospital Mortality
Authors: Lee Christine K. , Hofer Ira , Gabel Eilon , Baldi Pierre , Cannesson Maxime
Published: April 2018

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

The authors tested the hypothesis that deep neural networks trained on intraoperative features can predict postoperative in-hospital mortality.

Methods

The data used to train and validate the algorithm consists of 59,985 patients with 87 features extracted at the end of surgery. Feed-forward networks with a logistic output were trained using stochastic gradient descent with momentum. The deep neural networks were trained on 80% of the data, with 20% reserved for testing. The authors assessed improvement of the deep neural network by adding American Society of Anesthesiologists (ASA) Physical Status Classification and robustness of the deep neural network to a reduced feature set. The networks were then compared to ASA Physical Status, logistic regression, and other published clinical scores including the Surgical Apgar, Preoperative Score to Predict Postoperative Mortality, Risk Quantification Index, and the Risk Stratification Index.

Results

In-hospital mortality in the training and test sets were 0.81% and 0.73%. The deep neural network with a reduced feature set and ASA Physical Status classification had the highest area under the receiver operating characteristics curve, 0.91 (95% CI, 0.88 to 0.93). The highest logistic regression area under the curve was found with a reduced feature set and ASA Physical Status (0.90, 95% CI, 0.87 to 0.93). The Risk Stratification Index had the highest area under the receiver operating characteristics curve, at 0.97 (95% CI, 0.94 to 0.99).

Conclusions

Deep neural networks can predict in-hospital mortality based on automatically extractable intraoperative data, but are not (yet) superior to existing methods.
γ-Aminobutyric Acid Type A Receptor Potentiation Inhibits Learning in a Computational Network Model
Authors: Storer Kingsley P. , Reeke George N.
Published: April 2018

Background

Propofol produces memory impairment at concentrations well below those abolishing consciousness. Episodic memory, mediated by the hippocampus, is most sensitive. Two potentially overlapping scenarios may explain how γ-aminobutyric acid receptor type A (GABAA) potentiation by propofol disrupts episodic memory—the first mediated by shifting the balance from excitation to inhibition while the second involves disruption of rhythmic oscillations. We use a hippocampal network model to explore these scenarios. The basis for these experiments is the proposal that the brain represents memories as groups of anatomically dispersed strongly connected neurons.

Methods

A neuronal network with connections modified by synaptic plasticity was exposed to patterned stimuli, after which spiking output demonstrated evidence of stimulus-related neuronal group development analogous to memory formation. The effect of GABAA potentiation on this memory model was studied in 100 unique networks.

Results

GABAA potentiation consistent with moderate propofol effects reduced neuronal group size formed in response to a patterned stimulus by around 70%. Concurrently, accuracy of a Bayesian classifier in identifying learned patterns in the network output was reduced. Greater potentiation led to near total failure of group formation. Theta rhythm variations had no effect on group size or classifier accuracy.

Conclusions

Memory formation is widely thought to depend on changes in neuronal connection strengths during learning that enable neuronal groups to respond with greater facility to familiar stimuli. This experiment suggests the ability to form such groups is sensitive to alteration in the balance between excitation and inhibition such as that resulting from administration of a γ-aminobutyric acid–mediated anesthetic agent.
Tibial Fracture Nonunion and Time to Healing After Reamed Intramedullary Nailing: Risk Factors Based on a Single-Center Review of 1003 Patients
Authors: Dailey Hannah L. , Wu Katherine A. , Wu Ping-Shi , McQueen Margaret M. , Court-Brown Charles M.
Published: April 2018

Objective:

To determine factors associated with nonunion of adult tibial fractures.

Design:

Retrospective review with data collection for logistic regression and survival analysis.

Setting:

Scottish Level I trauma center, 1985–2007.

Patients:

During this period, 1590 adult tibial fractures were treated by reamed nailing and 1003 fractures met all inclusion criteria for the chosen analysis.

Intervention:

Reamed intramedullary nailing.

Main Outcome Measures:

Record of nonunion diagnosis and final union time with characteristics, including age, gender, closed or open injury, OTA/AO classification, Gustilo classification, fasciotomy, infection, polytrauma, smoking, and injury severity score.

Results:

The overall nonunion rate was 12%, and median time to healing was 18 weeks. Age significantly influenced nonunion, with middle-aged patients at highest risk. Both fracture type (closed/open) and morphology (OTA/AO classification) significantly influenced nonunion risk and time to union. Among closed injuries, the highest nonunion rate was for OTA/AO type B fractures (15%). Among open injuries, the highest nonunion rate was for OTA/AO type C (61%). Both compartment syndrome and smoking did not significantly influence nonunion risk but did significantly extend time to union.

Conclusions:

Injury characteristics including fracture morphology and severity of soft tissue injury were strong predictors of compromised fracture healing. Age also influenced nonunion risk in an unexpected way, with highest rates in the middle decades of adulthood. Future studies should consider the possibility of similar age-related effects and clinical studies should seek to identify explanations for why this may arise, including both physiological and socio-behavioral factors.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Should All Orthopaedists Perform Hemiarthroplasty for Femoral Neck Fractures? A Volume–Outcome Analysis
Authors: Clement R. Carter , Strassle Paula D. , Ostrum Robert F.
Published: April 2018

Objectives:

To determine whether very low surgeon and hospital hip arthroplasty volumes are associated with unfavorable outcomes after hemiarthroplasty for femoral neck fractures.

Methods:

Patients ≥60 years of age and who underwent hemiarthroplasty for femoral neck fracture were identified in the New York Statewide Planning and Research Cooperative System data from 2001 to 2015. Incidence of inpatient mortality and postoperative complications were compared across both surgeon and hospital volume using multivariable Cox proportional hazards regression, adjusting for clinical and demographic factors.

Results:

Fifty eight thousand eight hundred fourteen patients were included. Low surgeon volume (1 case/year) was associated with increased complications [hazard ratio (HR) 1.35, 95% CI, 1.26–1.44, P < 0.0001), including dislocations (HR 1.31 95% CI, 1.04–1.65, P = 0.02) and several medical complications (P = 0.003) compared with surgeons performing at least 2 hip arthroplasties/year. Low hospital volume (<20 cases/year) was associated with increased complications (HR 1.11, 95% CI, 1.02–1.20, P = 0.02), including deep infections (HR 1.39, 95% CI, 1.02–1.89, P = 0.04) and certain medical complications (P = 0.02) compared with centers performing at least 50 hip arthroplasties/year. Hospital and surgeon volume were not associated with inpatient mortality (P = 0.98) or reoperations (P = 0.40).

Conclusions:

Providers who rarely perform hemiarthroplasty for femoral neck fractures should defer these cases to surgeons and hospitals who regularly perform hip arthroplasty. Additional research is needed to further characterize the thresholds for “low volume” and to determine whether there is additional benefit afforded by high-volume surgeons and hospitals (or if it is adequate that providers performing hemiarthroplasty maintain volumes above relatively low thresholds as identified here).

Level of Evidence:

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Biomechanical Testing of a 3-Hole Versus a 4-Hole Sliding Hip Screw in the Presence of a Retrograde Intramedullary Nail for Ipsilateral Intertrochanteric and Femur Shaft Fractures
Authors: Olsen Michael , Goshulak Peter , Crookshank Meghan C. , Moktar Joel , Brazda Ignace J. , Schemitsch Emil H. , Zdero Radovan
Published: April 2018

Objective:

The goal of this study was to compare a 3-hole versus a 4-hole sliding hip screw (SHS) in the presence of a retrograde intramedullary (RIM) nail for fixing intertrochanteric and comminuted midshaft femur fractures.

Methods:

Mechanical tests were performed on 10 matched pairs of human cadaveric femurs that were osteotomized and then fixed using a 3-hole SHS versus the traditional “gold standard” 4-hole SHS in the presence of an RIM nail.

Results:

Data showed no differences between the 3-hole SHS with RIM nail versus 4-hole SHS with RIM nail for stiffness (281 ± 127 vs. 260 ± 118 N/mm, P = 0.76), clinical failure at 10 mm of hip displacement (2014 ± 363 vs. 2134 ± 614 N, P = 0.52), or ultimate mechanical failure (3476 ± 776 vs. 3669 ± 755 N, P = 0.12).

Conclusions:

For this fracture pattern, a 3-hole SHS with RIM nail may be a suitable surgical alternative to the traditional “gold standard” method because it provides the same biomechanical properties while potentially reducing surgical time, blood loss, and hardware used.
Evaluating the Accuracy and Quality of the Information in Kyphosis Videos Shared on YouTube
Authors: Erdem Mehmet Nuri , Karaca Sinan
Published: April 2018

Study Design.

A quality-control YouTube-based study using the recognized quality scoring systems.

Objective.

In this study, our aim was to confirm the accuracy and quality of the information in kyphosis videos shared on YouTube.

Summary of Background Data.

The Internet is a widely and increasingly used source for obtaining medical information both by patients and clinicians. YouTube, in particular, manifests itself as a leading source with its ease of access to information and visual advantage for Internet users.

Methods.

The first 50 videos returned by the YouTube search engine in response to “kyphosis” keyword query were included in the study and categorized under seven and six groups, based on their source and content. The popularity of the videos was evaluated with a new index called the video power index (VPI). The quality, educational quality, and accuracy of the source of information were measured using theJournal of American Medical Association(JAMA) score, Global Quality Score (GQS), and Kyphosis-Specific Score (KSS).

Results.

Videos had a mean duration of 397 seconds and a mean number of 131,644 views, with a total viewing number of 6,582,221. The source (uploader) in 36% of the videos was a trainer and the content in 46% of the videos was exercise training. Seventy-two percent of the videos were about postural kyphosis. Videos had a mean JAMA score of 1.36 (range: 1–4), GQS of 1.68 (range: 1–5), and KSS of 3.02 (range: 0–32). The academic group had the highest scores and the lowest VPIs.

Conclusion.

Online information on kyphosis is low quality and its contents are of unknown source and accuracy. In order to keep the balance in sharing the right information with the patient, clinicians should possess knowledge about the online information related to their field and should contribute to the development of optimal medical videos.

Level of Evidence:3
Postoperative Status of Global Sagittal Alignment With Compensation in Adult Spinal Deformity
Authors: Inami Satoshi , Moridaira Hiroshi , Takeuchi Daisaku , Ueda Haruki , Shiba Yo , Asano Futoshi , Aoki Hiromichi , Taneichi Hiroshi
Published: April 2018

Study Design.

A retrospective study of consecutive patients undergoing surgery for adult spinal deformity (ASD).

Objective.

The aim of this study was to classify postoperative ASD patients by sagittal compensation and characterize the features of each group.

Summary of Background Data.

Sagittal compensatory mechanisms to keep the erect position would function in not only nonoperative ASD patients but also in postoperative patients. However, details of sagittal compensatory mechanisms after surgery have been unclear, because the majority of previous studies examined the compensatory mechanisms in nonoperative patients.

Methods.

A total of 73 postoperative ASD patients were recruited. Spinopelvic parameters and Oswestry Disability Index (ODI) were measured before surgery, at 1-month and 2-year follow-up. The changes in parameters (Δ) between postoperative 1-month and 2-year were also evaluated. Cluster analysis based on pelvic tilt (PT) and sagittal vertical axis (SVA) at 2-year follow-up was performed, and then the parameters were compared among clusters.

Results.

Cluster analysis identified three clusters: the physiological group (n = 38, PT = 19.6°, SVA = 17.2 mm), the compensated group (n = 23, PT = 34.3°, SVA = 45.6 mm), and the decompensated group (n = 12, PT = 36.6°, SVA = 118.8 mm). Comparisons of the parameters among the groups showed that the physiological group had smaller pelvic incidence minus lumbar lordosis (PI-LL) and better ODI. The compensated group had significantly larger Δ thoracic kyphosis (TK), Δ proximal junctional angle (PJA), and ΔPT than the physiological group. The decompensated group had significantly higher PI and higher age.

Conclusion.

Three groups were defined in terms of postoperative compensatory mechanisms. Patients in the physiological group had little postoperative alignment change and good ODI value. The compensated group had pelvic retroversion to keep SVA in the physiological range, but the compensation in the thoracic spine was unlikely to work. High PI and advanced age were characteristics of the decompensated group.

Level of Evidence: 4