The Efficacy of Peripheral Opioid Antagonists in Opioid-Induced Constipation and Postoperative Ileus: A Systematic Review of the Literature.

Opioid-induced constipation has a negative impact on quality of life for patients with chronic pain and can affect more than a third of patients. A related but separate entity is postoperative ileus, which is an abnormal pattern of gastrointestinal motility after surgery. Nonselective μ-opioid receptor antagonists reverse constipation and opioid-induced ileus but cross the blood-brain barrier and may reverse analgesia. Peripherally acting μ-opioid receptor antagonists target the μ-opioid receptor without reversing analgesia. Three such agents are US Food and Drug Administration approved. We reviewed the literature for randomized controlled trials that studied the efficacy of alvimopan, methylnaltrexone, and naloxegol in treating either opioid-induced constipation or postoperative ileus. Peripherally acting μ-opioid receptor antagonists may be effective in treating both opioid-induced bowel dysfunction and postoperative ileus, but definitive conclusions are not possible because of study inconsistency and the relatively low quality of evidence. Comparisons of agents are difficult because of heterogeneous end points and no head-to-head studies

In vivo investigation of the tissue response to commercial Teflon insulin infusion sets in large swine for 14 days: the effect of angle of insertion on tissue histology and insulin spread within the subcutaneous tissue.

Objective: This study investigated the effects of the inflammatory tissue response (ITR) to an insulin infusion set (IIS) on insulin bolus spread over wear time, as well as the effect of cannula insertion angle on the ITR, bolus shape, and pump tubing pressure. Research design and methods: Angled or straight IISs were inserted every other day for 14 days into the subcutaneous tissue of 11 swine and insulin was delivered continuously. Prior to euthanasia, a 70 µL bolus of insulin/X-ray contrast agent was infused while recording a pressure profile (peak tubing pressure, pmax; area under the pressure curve, AUC), followed by the excision of the tissue-catheter specimen. Bolus surface area (SA) and volume (V) were assessed via micro-CT. Tissue was stained to analyze total area of inflammation (TAI) and inflammatory layer thickness (ILT) surrounding the cannula. Results: A bolus delivered through an angled IIS had a larger mean SA than a bolus delivered through a straight cannula (314.0±84.2 mm2 vs 229.0±99.7 mm2, p\u3c0.001) and a larger volume (198.7±66.9 mm3 vs 145.0±65.9 mm3, p=0.001). Both decreased significantly over wear time, independent of angle. There was a significant difference in TAI (angled, 9.1±4.0 mm2 vs straight, 14.3±8.6 mm2, p\u3c0.001) and ILT (angled, 0.7±0.4 vs straight, 1.2±0.7 mm, p\u3c0.001). pmax (p=0.005) and AUC (p=0.014) were lower using angled IIS. As ILT increased, pmax increased, while SA and V decreased. Conclusions: The progression of the ITR directly affected bolus shape and tubing pressure. Although straight insertion is clinically preferred, our data suggest that an angled IIS elicits lower grades of ITR and delivers a bolus with lower tubing pressure and greater SA and V. The subcutaneous environment plays a crucial role in IIS longevity, and the insertion angle needs to be considered in future IIS designs and clinical trials

Ketamine for Refractory Headache: A Retrospective Analysis.

BACKGROUND AND OBJECTIVES: The burden of chronic headache disorders in the United States is substantial. Some patients are treatment refractory. Ketamine, an N-methyl-D-aspartate antagonist, provides potent analgesia in subanesthetic doses in chronic pain, and limited data suggest it may alleviate headache in some patients. METHODS: We performed a retrospective study of 61 patients admitted over 3 years for 5 days of intravenous therapy that included continuous ketamine to determine responder rate and patient and ketamine infusion characteristics. Pain ratings at 2 follow-up visits were recorded. An immediate responder was a patient with decrease of 2 points or greater in the numerical rating scale (0-10) from start to final pain in the hospital. Sustained response at office visits 1 and 2 was determined based on maintaining the 2-point improvement at those visits. Patients were assessed daily for pain and adverse events (AEs). RESULTS: Forty-eight (77%) of the 61 patients were immediate responders. There were no differences regarding demographics, opioid use, or fibromyalgia between immediate responders and nonresponders. Maximum improvement occurred 4.56 days (mean) into treatment. Sustained response occurred in 40% of patients at visit 1 (mean, 38.1 days) and 39% of patients at visit 2 (mean, 101.3 days). The mean maximum ketamine rate was 65.2 ± 2.8 mg/h (0.76 mg/kg per hour). Ketamine rates did not differ between groups. Adverse events occurred equally in responders and nonresponders and were mild. CONCLUSIONS: Ketamine was associated with short-term analgesia in many refractory headache patients with tolerable adverse events. A prospective study is warranted to confirm this and elucidate responder characteristics

Constrained by managerialism : caring as participation in the voluntary social services

The data in this study show that care is a connective process, underlying and motivating participation and as a force that compels involvement in the lives of others, care is at least a micro-participative process. Care or affinity not only persisted in the face of opposition, but it was also used by workers as a counter discourse and set of practices with which to resist the erosion of worker participation and open up less autonomized practices and ways of connecting with fellow staff, clients and the communities they served. The data suggest that while managerialism and taylorised practice models may remove or reduce opportunities for worker participation, care is a theme or storyline that gave workers other ways to understand their work and why they did it, as well as ways they were prepared to resist managerial priorities and directives, including the erosion of various kinds of direct and indirect participation. The degree of resistance possible, even in the highly technocratic worksite in Australia, shows that cracks and fissures exist within managerialism

Konsekvenser at elektrifiering av fordon från elsystemets perspektiv

Klimatfrågan har ökat intresset för förnyelsebar energi inom både elproduktions- och transportsektorn. Från elproduktionens sida är vindkraft den teknik som växer snabbast. När vindkraft inkluderas i elkraftsystemet medför det att intermittens uppstår på elproduktionssidan. För transportsektorn har det diskuterats mycket kring elektrifiering av personbilen, som skulle kunna bli både ett miljövänligt (om elproduktionen kommer från förnyelsebar energi) alternativ till dagens konventionella bilar och ett sätt att reglera elproduktionen då en stor andel vindkraftsturbiner adderas till elproduktionssystemet. Syftet med detta examensarbete är att undersöka och analysera påverkan på den elektriska lastprofilen på grund av plug-in hybrid elektriska fordon (PHEVs) och effekten av en sådan förändrad last på produktionen i ett elsystem bestående av termiska anläggningar och vindanläggningar. PHEVs kan användas för att ersätta en stor andel av fossilt bränsle, som används av bilar i transportsektorn, med el från nätet. Elbilars laddning påverkar lastprofilen och beroende på elbilarnas antal, laddningskapacitet och laddningsmönster kan lasttoppar och lastvariationer komma att öka. Laddningsmöjligheterna varierar beroende på individens körbeteende och laddningsbehovet. Den typiska ägaren av PHEVs tenderar att använda eldriften för att pendla från bostaden till jobbet, vilket indikerar att de flesta laddningstoppar under dygnet inträffar mellan dessa resor. Eftersom topparna bestäms av bilförarnas resvanor medför detta också att lastvariationerna kommer att påverkas. Om variationen i lasten ökar så kan detta betyda att investeringar i elnätets infrastruktur blir aktuella för att minska risker för förluster och överbelastningar i detta. Ytterligare en nödvändig investering i infrastruktur är laddningsstationer för elbilar om laddningsmöjligheterna ska utökas. Med ett väl utarbetat och genomtänkt system, har den varierande elbilslasten istället potential att bli en flexibel last som kan användas för att minska lastvariationer och lasttoppar1. Tre scenarier för integration av PHEVs i västra Danmarks elsystem studeras. Scenarierna jämförs och analyseras med avseende på den totala elsystemkostnaden och jämförs också med fallet utan integration av PHEVs. Resultaten visar tydligt att oavsett vilken av de tre infrastrukturerna med PHEVs integration i elsystemet som väljs så medför det en ökning av den totala systemkostnaden. Detta beror på att oavsett om scenario 1, 2 eller 3 genomförs så leder PHEVs integration till en ökad lastvariation. Detta tyder på att PHEVs laddningstider måste kontrolleras aktivt med någon sorts styrning som minskar lastvariationen. Enligt resultat är scenario 2 (med laddningsmöjlighet alla pauser längre än 6 timmar) mer lämpat att implementera baserat på investeringskostnaden, jämfört med infrastruktur 3 (med laddningsmöjlighet alla pauser längre än 2 timmar). Den infrastruktur som antas kosta minst är infrastuktur 1, eftersom den erbjuder laddningsmöjligheter vid pauser på tio timmar och uppåt, vilket innebär att pausen sker vid fordonets bestämda parkeringsplats

Epifaunal Assemblages Associated with Dock Pilings in the Bocas del Toro Archipelago

Ascidians and bivalves demonstrate complex relationships through competition for space and mutual predation by sea stars. Ascidians often out-compete bivalves and other organisms for space when nutrient levels are high, such as around urban centers. Bivalves can struggle to settle where there is increased boat traffic and competition, and therefore can be found in higher abundance in rural areas. This study investigated the difference in abundance of bivalves and ascidians and the difference in species distribution of ascidians between urban and rural dock pilings. In April 2018, ten sampling sites around the Bocas del Toro archipelago of Panama were used to conduct the study, five sites being urban and five rural. This study aimed to determine how distance from the urban center of Bocas town affected these invertebrates and to infer overall ecosystem health in these artificial habitats. Overall, there was no relationship between ascidian and bivalve density, but there were significantly denser populations of bivalves found on rural pilings compared to urban pilings. An even distribution of prominent ascidian species was found through both urban and rural areas. The difference in bivalve distribution could be caused by differences in anthropogenic disturbance, suggesting that urban boat traffic and increased competition may have a large impact on the bivalve community. The even ascidian species distribution suggests a well-established artificial habitat that closely resembles local coral reefs and mangroves. Some urban and rural dock piling communities may then be positively contributing to the marine biodiversity and health in Bocas del Toro, Panama

Ventilation Method during Intensive Care Unit Transport after Cardiac Surgeries; When Should We Use A Ventilator?

Background Problem Statement: Manual ventilation with AMBU bag is utilized mostly for transporting post cardiac surgery patients to the intensive care unit, but some patients need mechanical ventilation due to concern for oxygenation, ventilation, and cardiac function. Also, transport can be a critical moment because of limited hemodynamic information and suboptimal environment for therapeutic intervention. Thus, risk stratification for appropriate ventilation is necessary for safe transport. • Project AIM: We assessed biventricular function (with a hand-held echocardiography), arterial blood gas, and hemodynamics pre and post transport in manual and mechanical ventilation groups

Microvolt T-Wave Alternans in Patients with a Biventricular Implantable Defibrillator

Background/Aim: Microvolt T-wave alternans (MTWA) has been found to be associated with cardiac electrical instability. The aim of this study was to investigate the effects of biventricular pacing on MTWA in comparison with other pacing modalities.Methods: The study group consisted of 50 patients with dilated or ischemic cardiomyopathy with a cardiac resynchronization therapy device. MTWA was measured during several pacing modalities.Results: Overall, 181 MTWA studies were performed in 50 patients. Seventy-nine studies (44%) were negative, 81(45%) were positive and 21 (12%) were indeterminate. With right atrial (RA) pacing, 45% of the MTWA tests were negative. With right ventricular (RV) pacing, 30 % were negative, with left ventricular (LV) pacing 44 % were negative and with biventricular pacing 52% of the tests were negative (P=0.15). The results of TWA testing were concordant between RA pacing and biventricular pacing (K=0.46, P=0.007).Conclusion: MTWA during biventricular pacing correlates with MTWA during atrial pacing and left ventricular pacing

Assessment of Hyperfibrinolysis in Liver Transplantation Surgery as Measured by Rotational Thromboelastometry

Hyperfibrinolysis is a significant concern during liver transplantation surgeries. Rotational thromboelastometry (ROTEM) is a point of care device that is capable of intraoperatively measuring the clotting properties of whole blood samples, including the rate of fibrinolysis. The aim of this study was to use ROTEM to determine if improved surgical techniques have lowered rates of hyperfibrinolysis during liver transplantations. Blood samples were taken from 284 patients during liver transplantations that took place over five years from 2014-2019. The blood samples were drawn at various time points during the preanhepatic phase, anhepatic phase, and neohepatic phase of the surgery. Hyperfibrinolysis was defined using an accepted ROTEM definition of a maximum lysis value (ML) greater than 15%. Preliminary results show that 14% of patients experienced hyperfibrinolysis at some point during the surgery, which is similar to rates that previous studies have reported (p-values are currently unknown, as mentioned above). Preoperative MELD score, preoperative INR, and intraoperative clot strength do not appear to be related to hyperfibrinolysis. Both increased age, and non-alcohol related liver diseases (hemochromatosis, hepatocellular carcinoma, Hepatitis C etc.) as the reason for transplantation show higher rates of hyperfibrinolysis. The study suggests that hyperfibrinolysis remains a serious concern in liver transplantation surgeries, despite improvements in surgical technique. In addition, the study also suggests that non-alcohol related liver diseases and increased age are significant risk factors for hyperfibrinolysis that deserve special hematological attention

Departures from isotropy: the kinematics of a larval snail in response to food

Author Posting. © Company of Biologists, 2020. This article is posted here by permission of Company of Biologists for personal use, not for redistribution. The definitive version was published in Journal of Experimental Biology 224(2), (2020): jeb.239178, https://doi.org/10.1242/jeb.239178.The swimming behavior of invertebrate larvae can affect their dispersal, survival and settlement in the ocean. Modeling this behavior accurately poses unique challenges as behavior is controlled by both physiology and environmental cues. Some larvae use cilia to both swim and create feeding currents, resulting in potential trade-offs between the two functions. Food availability is naturally patchy and often occurs in shallow horizontal layers in the ocean. Also, larval swimming motions generally differ in the horizontal and vertical directions. In order to investigate behavioral response to food by ciliated larvae, we measured their behavioral anisotropy by quantifying deviations from a model based on isotropic diffusion. We hypothesized that larvae would increase horizontal swimming and decrease vertical swimming after encountering food, which could lead to aggregation at food layers. We considered Crepidula fornicata larvae, which are specifically of interest as they exhibit unsteady and variable swimming behaviors that are difficult to categorize. We tracked the larvae in still water with and without food, with a portion of the larvae starved beforehand. On average, larvae in the presence of food were observed higher in the water column, with higher swimming speeds and higher horizontal swimming velocities when compared with larvae without food. Starved larvae also exhibited higher vertical velocities in food, suggesting no aggregation behavior. Although most treatments showed strong anisotropy in larval behavior, we found that starved larvae without food exhibited approximately isotropic kinematics, indicating that behavioral anisotropy can vary with environmental history and conditions to enhance foraging success or mitigate food-poor environments.M.H.D. and K.S.M.-K. were supported by postdoctoral scholarships from Woods Hole Oceanographic Institution, and B.T. was supported by a WHOI Summer Student Fellowship. This work was also supported by National Science Foundation grant OCE-0850419