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As malformações arteriovenosas (MAV) são anomalias congênitas que afetam a estrutura vascular e podem ocorrer tanto no pulmão quanto no cérebro. A fisiopatologia da MAV envolve um desvio anormal do fluxo sanguíneo arterial para as veias, sem passar pelos capilares, o que pode causar hipoxemia, insuficiência cardíaca e outras complicações. Os sintomas das malformações arteriovenosas pulmonares (MAVP) incluem dispneia, cianose, hemoptise e embolia pulmonar. Já as malformações arteriovenosas cerebrais (MAVC) podem apresentar sintomas como convulsões, cefaléia, hemorragia intracerebral e déficits neurológicos. Quanto à epidemiologia, a prevalência da MAVP é rara e ocorre duas vezes mais em mulheres do que em homens, exceto em recém-nascidos, enquanto a MAVC é mais comum, com uma prevalência estimada de varia de 1,12 a 1,42 casos por 100.000 pessoas/ano. Múltiplos fatores, como anormalidades vasculares, modificações moleculares e alterações de fluxo das artérias e veias, influenciam significativamente no desenvolvimento de MAVs. O diagnóstico da MAV envolve a realização de exames de imagem, como radiografia de tórax, tomografia computadorizada (TC) e ressonância nuclear magnética (RNM). Já a abordagem terapêutica da MAVP pode envolver embolização arterial ou cirurgia, dependendo da extensão da lesão. Já a MAVC pode ser tratada com embolização endovascular, cirurgia ou radioterapia, também dependendo das características da lesão. Assim, com o diagnóstico e tratamento adequados, muitos pacientes podem ter uma qualidade de vida satisfatória e prevenir complicações graves.

A Trombose Venosa Profunda (TVP) é uma condição médica grave caracterizada pela formação de um coágulo sanguíneo dentro das veias profundas do corpo, principalmente nas pernas. Quanto à epidemiologia, trata-se de uma doença comum em todo o mundo, afetando entre 2,5% a 5% da população. A prevalência da TVP aumenta com a idade e é maior em homens do que em mulheres. A fisiopatologia da TVP envolve a formação de coágulos sanguíneos nas veias profundas das pernas, o que pode ocorrer devido a uma variedade de fatores, incluindo imobilização prolongada, tabagismo, cirurgias, trauma, câncer, uso de contraceptivos orais, gravidez e pós-parto, fatores genéticos e obesidade. Quanto às manifestações clínicas, destacam-se dor, inchaço e vermelhidão nas pernas afetadas, bem como sensação de calor na pele sobre a veia afetada. No entanto, muitos casos de TVP são assintomáticos, o que torna o diagnóstico precoce desafiador. O diagnóstico da TVP envolve avaliação clínica, exames laboratoriais, exames de imagem, como ultrassonografia doppler, que podem detectar a presença de coágulos sanguíneos nas veias profundas das pernas. Já a abordagem terapêutica envolve o uso de medicamentos como anticoagulantes, que ajudam a prevenir a formação de novos coágulos sanguíneos e reduzem o risco de complicações graves. Em alguns casos, a remoção do coágulo pode ser necessária para prevenir complicações. A prevenção da TVP também é importante, especialmente em pessoas com fatores de risco, e pode envolver a mudança de estilo de vida e o uso de medicamentos preventivos.

In natural photosynthesis, the light-driven splitting of water into electrons, protons and molecular oxygen forms the first step of the solar-to-chemical energy conversion process. The reaction takes place in photosystem II, where the Mn4CaO5 cluster first stores four oxidizing equivalents, the S0 to S4 intermediate states in the Kok cycle, sequentially generated by photochemical charge separations in the reaction center and then catalyzes the O–O bond formation chemistry1–3. Here, we report room temperature snapshots by serial femtosecond X-ray crystallography to provide structural insights into the final reaction step of Kok’s photosynthetic water oxidation cycle, the S3→[S4]→S0 transition where O2 is formed and Kok’s water oxidation clock is reset. Our data reveal a complex sequence of events, which occur over micro- to milliseconds, comprising changes at the Mn4CaO5 cluster, its ligands and water pathways as well as controlled proton release through the hydrogen-bonding network of the Cl1 channel. Importantly, the extra O atom Ox, which was introduced as a bridging ligand between Ca and Mn1 during the S2→S3 transition4–6, disappears or relocates in parallel with Yz reduction starting at approximately 700 μs after the third flash. The onset of O2 evolution, as indicated by the shortening of the Mn1–Mn4 distance, occurs at around 1,200 μs, signifying the presence of a reduced intermediate, possibly a bound peroxide.

US-based academic institutions involved in global health (GH) partnerships can have a positive impact on healthcare systems in low/middle-income countries but lack a consistent approach. Existing priority setting and resource allocation (PSRA) frameworks do not adequately capture the interpersonal and sociopolitical complexity of decision-making in GH work. The authors explored how US-based GH practitioners prioritize and allocate resources for different types of support in academic GH partnerships.In 2020-2021, the authors invited 36 US-based GH practitioners from the 2015 Pediatric GH Leadership Conference to participate in individual one-hour semi-structured interviews. Using an iterative and inductive grounded theory approach, the study team analyzed interview transcripts through the lens of Heyse's framework on decision-making in humanitarian aid.The authors interviewed 20 GH practitioners and reached thematic sufficiency. A descriptive conceptual framework, capturing 18 distinct themes in four major categories, emerged from the data. In this framework, categories included: 1) stakeholders: those who influence and are influenced by the partnership; 2) goals: vision, mission, aims, and scope of the partnership; 3) implementation strategy: approach to accomplishing goals, categorized as relationship-oriented, task-oriented, context-oriented, or nonprescriptive; and 4) approach to conflict: response when goals and strategies do not align among stakeholders.Themes revealed a dynamic process for PSRA. Using our study findings, and building on existing literature, our framework highlights the complex interpersonal relationships, resource limitations, and sociopolitical and economic constraints that affect PSRA in GH partnerships. Finally, themes point to the field's evolution towards a more decolonized approach to GH.This work outlines a process-oriented descriptive framework for prioritization and resource allocation in global health partnerships. The framework provides a tool to help global health practitioners critically interrogate partnerships.

Aim The German osteoporosis guideline was updated on the basis of a systematic literature review and through a structured consensus process by an interdisciplinary, international (Germany, Austria, Switzerland) expert group representing the 20 member societies of the Joint Osteological Association (DVO) and patient advocacy organizations (BfO). This manuscript summarizes the changes in the German osteoporosis guideline with regard to pharmacological interventions and offers pragmatic pathways for implementation. Method Systematic literature search and structured consensus building according to AWMF regulations. Results The sclerostin antibody romosozumab was adopted into the guideline. In addition, the effectiveness of teriparatide was re-evaluated. For both bone anabolic agents evidence from randomized trials underlined a superiority over oral bisphosphonates with regard to fracture risk reduction. Between the antiresorptive treatments, differences regarding superiority/inferiority could only be shown with respect to surrogate parameters, not with regard to fractures. Data about the duration of treatment of all available drugs is limited. All non-bisphosphonate treatments require follow-up treatment. Conclusion An individualized treatment concept should be developed in a shared decision process, including a bone anabolic-first strategy in high-risk patients. Recommendations on treatment duration, drug holidays and sequential strategies should be considered.

In this paper, we present observations of two high-resolution transit datasets obtained with ESPRESSO of the bloated sub-Saturn planet WASP-131~b. We have simultaneous photometric observations with NGTS and EulerCam. In addition, we utilised photometric lightcurves from {\tess}, WASP, EulerCam and TRAPPIST of multiple transits to fit for the planetary parameters and update the ephemeris. We spatially resolve the stellar surface of WASP-131 utilising the Reloaded Rossiter McLaughlin technique to search for centre-to-limb convective variations, stellar differential rotation, and to determine the star-planet obliquity for the first time. We find WASP-131 is misaligned on a nearly retrograde orbit with a projected obliquity of $\lambda = 162.4\substack{+1.3 \\ -1.2}^{\circ}$. In addition, we determined a stellar differential rotation shear of $\alpha = 0.61 \pm 0.06$ and disentangled the stellar inclination ($i_* = 40.9\substack{+13.3 \\ -8.5}^{\circ}$) from the projected rotational velocity, resulting in an equatorial velocity of $v_{\rm{eq}} = 7.7\substack{+1.5 \\ -1.3}$~km s$^{-1}$. In turn, we determined the true 3D obliquity of $\psi = 123.7\substack{+12.8 \\ -8.0}^{\circ}$, meaning the planet is on a perpendicular/polar orbit. Therefore, we explored possible mechanisms for the planetary system's formation and evolution. Finally, we searched for centre-to-limb convective variations where there was a null detection, indicating that centre-to-limb convective variations are not prominent in this star or are hidden within red noise., Comment: 15 Pages, 10 Figures and 4 Tables Accepted for Publication in MNRAS. arXiv admin note: text overlap with arXiv:2207.10127

The aim of study is to examine patient emotional cues to oncologists’ responses and explore the association between the concerns and emotional cues during the consultation and the physicians’ response to them throughout treatment, satisfaction, and the assessment of the patients’ perception of the established communication. Cross-sectional design, involved 12 adults patients undergoing cancer treatment and eight physicians in the study. The twelve video-recorded medical consultations werecoded (349 cues/concern) using the Verona coding definitions of emotional sequences (VR-CoDES). A strong association between explicit with reducing space responses and the physiological symptoms cues (x²=6.029; p=0.014), and related to the repetition cue of the content by the patient (x²=5.599; p=0.018) was observed. Patients expressed fewer non-verbal behaviors (for example, crying, silence, silent pauses), as they had been undergoing treatment for a longer time, therefore, provided with more empathic responses from physicians. The identification of emotions can help physicians to further explore patients’ underlying cues that reveal emotional distress concerning illness and treatment in a less explicit way. There is a need for improvement in the physician’s ability to recognize patients’ concerns and to provide space for patients to have comprehensive health care, considering the severity of cancer disease and its negative emotional impacts for patients.

Precision antenna calibration is required for mitigating the impact of foreground contamination in 21 cm cosmological radio surveys. One widely studied source of error is the effect of missing point sources in the calibration sky model; however, poorly understood diffuse galactic emission also creates a calibration bias that can complicate the clean separation of foregrounds from the 21 cm signal. In this work, we present a technique for suppressing this bias with temporal filtering of radio interferometric visibilities observed in a drift-scan mode. We demonstrate this technique on mock simulations of the Hydrogen Epoch of Reionization Array (HERA) experiment. Inspecting the recovered calibration solutions, we find that our technique reduces spurious errors by over an order of magnitude. This improved accuracy approaches the required accuracy needed to make a fiducial detection of the 21 cm signal with HERA, but is dependent on a number of external factors that we discuss. We also explore different types of temporal filtering techniques and discuss their relative performance and trade-offs.

Der Beitrag illustriert das Angebot an staatlich unterstützter Förderung von Erstsprachen schulpflichtiger Kinder anhand von Daten aus der Zentralschweiz. Der vorhandene herkunftssprachliche Unterricht (HSU) wird mit der potenziellen «sprachlichen Nachfrage» – den in den Kantonen dokumentierten Erstsprachen – kontrastiert. Die Analyse macht kantonale Unterschiede sowie Desiderata bezüglich des HSU-Angebots und der Förderung der Erstsprachkompetenzen sichtbar. Der Artikel schliesst mit einem Plädoyer für eine integrative Mehrsprachigkeitsdidaktik, die den HSU inkludiert und die gesamtsprachlichen Repertoires der Schüler:innen als Ressource berücksichtigt.

BackgroundThe key Alzheimer’s disease (AD) biomarkers are traditionally measured with techniques/exams that are either expensive (amyloid-positron emission tomography (PET) and tau-PET), invasive (cerebrospinal fluid Aβ42and p-tau181), or poorly specific (atrophy on MRI and hypometabolism on fluorodeoxyglucose-PET). Recently developed plasma biomarkers could significantly enhance the efficiency of the diagnostic pathway in memory clinics and improve patient care. This study aimed to: (1) confirm the correlations between plasma and traditional AD biomarkers, (2) assess the diagnostic accuracy of plasma biomarkers as compared with traditional biomarkers, and (3) estimate the proportion of traditional exams potentially saved thanks to the use of plasma biomarkers.MethodsParticipants were 200 patients with plasma biomarkers and at least one traditional biomarker collected within 12 months.ResultsOverall, plasma biomarkers significantly correlated with biomarkers assessed through traditional techniques: up tor=0.50 (pr=0.43 (p=0.002) among tau, andr=−0.23 (p=0.001) among neurodegeneration biomarkers. Moreover, plasma biomarkers showed high accuracy in discriminating the biomarker status (normal or abnormal) determined by using traditional biomarkers: up to area under the curve (AUC)=0.87 for amyloid, AUC=0.82 for tau, and AUC=0.63 for neurodegeneration status. The use of plasma as a gateway to traditional biomarkers using cohort-specific thresholds (with 95% sensitivity and 95% specificity) could save up to 49% of amyloid, 38% of tau, and 16% of neurodegeneration biomarkers.ConclusionThe implementation of plasma biomarkers could save a remarkable proportion of more expensive traditional exams, making the diagnostic workup more cost-effective and improving patient care.

Assessment of vancomycin-resistant Enterococcus faecium (VREfm) prevalence upon hospital admission and analysis of risk factors for colonization.From 2014 to 2018, patients were recruited within 72 hours of admission to seven participating German university hospitals, screened for VREfm and questioned for potential risk factors (prior multidrug-resistant organism detection, current/prior antibiotic consumption, prior hospital, rehabilitation or long-term care facility stay, international travel, animal contact and proton pump inhibitor [PPI]/antacid therapy). Genotype analysis was done using cgMLST typing. Multivariable analysis was performed.In 5 years, 265 of 17,349 included patients were colonized with VREfm (a prevalence of 1.5%). Risk factors for VREfm colonization were age (adjusted OR [aOR], 1.02; 95% CI, 1.01-1.03), previous (aOR, 2.71; 95% CI, 1.87-3.92) or current (aOR, 2.91; 95% CI, 2.60-3.24) antibiotic treatment, prior multidrug-resistant organism detection (aOR, 2.83; 95% CI, 2.21-3.63), prior stay in a long-term care facility (aOR, 2.19; 95% CI, 1.62-2.97), prior stay in a hospital (aOR, 2.91; 95% CI, 2.05-4.13) and prior consumption of PPI/antacids (aOR, 1.29; 95% CI, 1.18-1.41). Overall, the VREfm admission prevalence increased by 33% each year and 2% each year of life. 250 of 265 isolates were genotyped and 141 (53.2%) of the VREfm were the emerging ST117. Multivariable analysis showed that ST117 and non-ST117 VREfm colonized patients differed with respect to admission year and prior multidrug-resistant organism detection.Age, healthcare contacts and antibiotic and PPI/antacid consumption increase the individual risk of VREfm colonization. The VREfm admission prevalence increase in Germany is mainly driven by the emergence of ST117.

Purpose: To examine the current pedagogical practices among physical educators with different dispositions toward the change process and belonging to different demographic categories. We hypothesized that change-disposed, nonchange-disposed, and neutral change disposition teachers, along with teachers of different gender identities and student grade level(s), implement “best practices” with differing frequencies. Methods: Eight hundred thirty U.S. physical educators completed the Teacher Change Questionnaire-Physical Education and a 15-item adaption of Society of Health and Physical Educators America’s 20 Indicators of Effective Physical Education Instruction. Results: Nonchange-disposed teachers more frequently provided objective-related feedback, provided assessment for differentiation and summative evaluation, ensured 50% student moderate to vigorous physical activity during physical education classes, and set student learning goals than change-disposed or neutral change disposition teachers. Female and elementary teachers reported more frequent use of written curriculum and assigned grades based on student knowledge/skill assessment than male and secondary counterparts. Discussion: Continuing professional development initiatives should be designed with consideration given to change disposition, gender identity, and grade level.

Objective To assess the natural history of saphenous and non-saphenous varicose veins using the results of the Bonn Vein Studies and data published in literature. Methods We used the data of the Bonn Vein Studies (BVS) 1 and 2 to assess if preexisting non-saphenous varicose veins (NSVV) in persons who had no saphenous varicose veins (SVV) at baseline have an impact on the incidence of SVV during the follow-up of 6.6 years and vice versa. SVV where defined as tortuous or not-tortuous refluxing saphenous veins. The statistical evaluation was performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). In addition, we performed a review of publications concerning the natural history of varicose veins (VV) using PubMed. Results In the BVS the overall incidence of SVV within the follow-up time of 6.6 years was 8.0 % (n = 133 of 1661; 95 % CI: 6.8–9.4). 7.2 % (n = 107 of 1492) without VV in BVS 1 and 19.8 % (n = 26) of patients with preexisting NSVV developed SVV. The relative risk for the development of SVV in patients with preexisting NSVV was 2.44 (95% CI: 1.64–3.64) adjusted for age and sex. The overall incidence of NSVV was markedly higher with 13.3 % (n = 226 of 1661; 95 % CI: 11.8–15.1). During follow-up 148 patients (9.9 %) without VV in BVS 1 developed NSVV. 48.5 % (n = 78) of patients with preexisting SVV developed NSVV during follow-up. The relative risk for the development of NSVV in patients with preexisting SVV was 4.10 (95% CI: 3.26–5.16), adjusted for age and sex.In published studies the development of VV is preceded by venous reflux. Initial VV may develop at any segment and the results from literature suggest that the location of VV and reflux at the time of the investigation depends on age. In younger individuals more distal location are reported with an ascending progression in the majority but also descending progression is possible. Conclusions Based on the results of the Bonn Vein Studies 1 and 2 we could demonstrate, that preexisting SVV increase the risk of developing NSVV and preexisting NSVV increase the risk of developing SVV in a similar way. Venous reflux may initially occur in any segment of the venous system and may progress in antegrade and/or retrograde fashion. In younger adults initial VV seem to be localized more often in distal parts of the legs with an antegrade progression over time.

BACKGROUND : Hospitalized patients are at risk for malnutrition. Decreased BMI (Body Mass Index) in stroke patients is negatively correlated with patient outcomes. Studies on differences in BMI and NIHSS (National Institutes of Health Stroke Scale) at admission and discharge in stroke patients have not been conducted in Indonesia. OBJECTIVE: To describe the difference between BMI and NIHSS at admission and discharge in ischemic stroke patients at Dr. Kariadi hospital METHOD : An observational study on 49 hospitalized ischemic stroke patients at the Stroke Unit of dr. Kariadi hospital. Outcomes were measured using the National Institutes of Stroke Scale (NIHSS). Data was collected from the patient's medical record and analyzed using Paired Sample t Test. RESULT : There was no significant difference between BMI at admission and discharge (p = 0.161). There was a significant difference between the NIHSS at the time of admission and at the time of discharge (p= 0.014). CONCLUSION : There is no significant difference between BMI at admission and discharge. There is functional improvement in ischemic stroke patients during treatment

Purpose: The study aimed to investigate the effects of a sugar-based structure, i.e. XAX (Xylitylglucoside-Anhydroxylitol-Xylitol) on skin barrier function and moisturization, both in vitro and in vivo, and to compare its efficacy with that of glycerin.Methods: Expression of genes was investigated by RT-qPCR analysis on topically-treated human reconstructed epidermis. Ceramide neosynthesis was measured by chromatography in topically-treated human skin explants. Production of essential proteins was monitored in primary cell cultures: Chondroitin sulfate and hyaluronic acid in fibroblasts, using chromatography; hyaluronic acid in keratinocytes, using ELISA. In vivo, epidermal microrelief, skin capacitance and transepidermal water loss (TEWL) were measured on 25 female volunteers with dry skin. Skin capacitance and TEWL were also measured, on hands, comparing hydroalcoholic gels.Results: XAX increased the expression of key moisturizing-related genes, such as enzymes, structural components or regulators of inter-keratinocytes junctions, cornified layer, desquamation process, as well as skin barrier function and hydration. It also increased the contents of ceramides, hyaluronic acid and chondroitin sulfate. In vivo, XAX treatment at 3% decreased TEWL and increased skin capacitance, skin microrelief and desquamation. The combination of XAX+glycerin (1.5%+1.5%) showed interesting effects compared to glycerin alone.Conclusion: XAX promoted effects on the biological pathways involved in skin barrier function; epidermal and dermal water reserves; and epidermal water circulation. Its effectiveness, confirmed in vivo, alone and in combination with glycerin, makes it an interesting alternative to basic emollients, humectants and occlusives.

Objective: To assess the impact of extended-release (ER)/long-acting (LA) opioid prescriber training on prescribing behaviors.Design: Retrospective cohort study.Setting: Prescriber training was evaluated from June 1, 2013 through December 31, 2016. The full study period was 2 years longer, from June 1, 2012 through December 31, 2017, to include data for all prescribers’ 1-year pretraining and post-training periods.Participants: 24,428 prescribers who wrote ER/LA opioid prescriptions for eligible patients, with a record of training from the partner continuing education provider between June 1, 2013 and December 31, 2016.Intervention: ER/LA opioid prescriber training. Main outcome measures: Prescribing behaviors 1-year before (pretraining) and after (post-training) prescribers completed training, specifically the proportion of opioid-nontolerant patients receiving ER/LA opioids indicated for opioid-tolerant patients and for patients receiving ≥100 morphine equivalents dose daily, and the proportion of concomitant users of central nervous system depressant drugs.Results: The differences in the proportion of opioid-nontolerant patients receiving ER/LA opioids indicated for opioid-tolerant patients and for patients receiving ≥100 morphine equivalents dose daily were –0.69 percent (95 percent confidence interval [CI]: –1.78 percent, 0.40 percent) and –0.23 percent (95 percent CI: –1.18 percent, 0.68 percent), respectively. The differences in the proportion of concomitant users of central nervous system depressant drugs were –0.94 percent (95 percent CI: –1.39 percent; –0.48 percent) for benzodiazepines, 0.06 percent (95 percent CI: –0.13 percent; 0.25 percent) for antipsychotics, –0.41 percent (95 percent CI: –0.69 percent; –0.13 percent) for hypnotics/sedatives, and 0.08 percent (95 percent CI: –0.40 percent; 0.57 percent) for muscle relaxants.Conclusions: While prescribers showed some changes in prescribing behavior after completing training, training was not associated with clinically relevant changes in prescribing behaviors.

While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis.Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture.Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives.We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level.Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery.All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cmFor the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion.In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.

Objective: To assess the impact of extended-release (ER)/long-acting (LA) opioid prescriber training on prescribing behaviors.Design: Retrospective cohort study.Setting: Prescriber training was evaluated from June 1, 2013 through December 31, 2016. The full study period was 2 years longer, from June 1, 2012 through December 31, 2017, to include data for all prescribers’ 1-year pretraining and post-training periods.Participants: 24,428 prescribers who wrote ER/LA opioid prescriptions for eligible patients, with a record of training from the partner continuing education provider between June 1, 2013 and December 31, 2016.Intervention: ER/LA opioid prescriber training. Main outcome measures: Prescribing behaviors 1-year before (pretraining) and after (post-training) prescribers completed training, specifically the proportion of opioid-nontolerant patients receiving ER/LA opioids indicated for opioid-tolerant patients and for patients receiving ≥100 morphine equivalents dose daily, and the proportion of concomitant users of central nervous system depressant drugs.Results: The differences in the proportion of opioid-nontolerant patients receiving ER/LA opioids indicated for opioid-tolerant patients and for patients receiving ≥100 morphine equivalents dose daily were –0.69 percent (95 percent confidence interval [CI]: –1.78 percent, 0.40 percent) and –0.23 percent (95 percent CI: –1.18 percent, 0.68 percent), respectively. The differences in the proportion of concomitant users of central nervous system depressant drugs were –0.94 percent (95 percent CI: –1.39 percent; –0.48 percent) for benzodiazepines, 0.06 percent (95 percent CI: –0.13 percent; 0.25 percent) for antipsychotics, –0.41 percent (95 percent CI: –0.69 percent; –0.13 percent) for hypnotics/sedatives, and 0.08 percent (95 percent CI: –0.40 percent; 0.57 percent) for muscle relaxants.Conclusions: While prescribers showed some changes in prescribing behavior after completing training, training was not associated with clinically relevant changes in prescribing behaviors.