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Background: Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids.Methods: Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores.Results: We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09).Conclusions: Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge. [ABSTRACT FROM AUTHOR]

Objective: Opioid side effects are common when treating chronic pain. However, the frequency of opioid side effects has rarely been examined in acute pain conditions, particularly in a post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid-induced side effects (constipation, nausea/vomiting, dizziness, drowsiness, sweating, and weakness) in patients discharged from the ED with an opioid prescription.Methods: This is a prospective cohort study of patients aged ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects.Results: We recruited 386 patients with a median age of 54 years (IQR:43-66); 50% were women. During the 2-week follow-up, 80% of patients consumed opioids. Among the patients who used opioids, 79% (95%CI:75-83) reported side effects compared to 38% (95%CI:27-49) for non-users. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report constipation (OR:7.5; 95%CI:3.1-17.9), nausea/vomiting (OR:4.1; 95%CI:1.8-9.5), dizziness (OR:5.4; 95%CI: 2.2-13.2), drowsiness (OR:4.6; 95%CI:2.5-8.7), and weakness (OR:4.2; 95%CI:1.6-11.0) compared to non-users. A dose-response trend was observed for constipation but not for the other side effects. Nausea/vomiting (OR:2.0; 95%CI:1.1-3.6) and dizziness (OR:1.9; 95%CI:1.1-3.4) were more often associated with oxycodone than with morphine.Conclusion: As observed for chronic pain treatment, side effects are highly prevalent during short-term opioid treatment for acute pain. Physicians should inform patients about those side effects and should consider prescribing laxatives. [ABSTRACT FROM AUTHOR]

Market prices of seafood underpin harvest and management strategies for fisheries and aquaculture. Beche-de-mer (processed, dried sea cucumbers) are highly valued in Asian markets. Market prices of Pacific Island beche-de-mer were previously reported from data collected in 2011. Recent economic slowdown in China and government austerity policy have dampened demand for certain luxury seafood products. This study presents updated data on prices, and relationships with product size, of beche-de-mer from 24 species of Indo-Pacific sea cucumbers sold in Hong Kong and Guangzhou, China. Average retail prices were highest in Hong Kong. Prices per individual increased exponentially with increasing beche-de-mer length for three high-value species, Holothuria fuscogilva (white teatfish), H. lessoni (golden sandfish) and H. scabra (sandfish). However, for seven other species, price per unit weight did not relate significantly to product length. Across 20 species, average prices increased by an average of 16.6% from 2011 to 2016, equating to an increase of 2.4% p.a., slightly exceeding China’s average CPI increase over the same period (2.1% p.a.). Products that were traditionally lower value appear more accepted in the marketplace. The analysed relationships offer rationale for large minimum legal size limits to improve the economic performance of fisheries for the high-value species H. fuscogilva, H. lessoni and H. scabra . The disproportionately high prices for larger specimens of these species also challenge a rethink of optimal harvest strategies for aquaculture operations. Lastly, the findings provide evidence of increasing demand and retail prices for these luxury seafood products in an ambiguous market climate. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is a well documented complication following lower limb trauma and surgery. The incidence of VTE in hip and knee surgery has been well studied, whereas the incidence in foot and ankle surgery is less clear. There is debate as to which cases require prophylaxis and what is the most effective means by which this is achieved. We performed a systematic review of the published English literature on VTE prophylaxis in foot and ankle surgery using MEDLINE, EMBASE, CINHAL, Cochrane Library, without date restrictions up to December 2012. From 988 citations, 25 papers fulfilled the inclusion criteria. Conclusions were drawn on the incidence (symptomatic and asymptomatic VTE), location (distal vs. proximal), associated risk factors, timing of VTE, role of mechanical and pharmacological prophylaxis and cost effectiveness of the treatment. Our review showed that the overall incidence of symptomatic VTE in foot and ankle surgery is low (0–0.55%). There is increased incidence in foot and ankle trauma patients with the highest incidence reported in tendo-achilles surgery. The reported risk factors include previous history of VTE, immobilisation, high BMI, age, co morbidities, contraceptive pill, and air-travel. There is a cumulative effect resulting in higher risk when two or more risk factors are present. [ABSTRACT FROM AUTHOR]

Highlights: [•] Atmospheric moisture, as rainbow water, is influenced by terrestrial evapotranspiration. [•] Trees influence green, blue and rainbow water parts of the hydrological cycle. [•] Influence of tree cover on terrestrial rainfall and water cycle critically depends on location. [•] West African rainfall, esp. in Sahel, depends on East African evapotranspiration. [•] Geopolitical consequences of these types of forest-climate relations are yet to be explored. [ABSTRACT FROM AUTHOR]

Highlights: [•] We review some characteristics of tropical topoclimosequences (TCSs). [•] Past records show the key impact of the dry season length over the Rungwe TCS. [•] The dry season appears to be extending in the Rungwe. [•] Drought could be amplified through a positive feedback involving landuse. [•] Local but long-term monitoring of tropical highland end-members is critical. [ABSTRACT FROM AUTHOR]

Abstract: Background: Podiatric surgery is well established in the National Health Service (NHS) in the UK with over 50 podiatric surgery units. This paper aimed to evaluate patient experience and satisfaction following foot surgery within a NHS orthopaedic department before and after the appointment of a podiatric surgeon. It highlights relevant labour force issues. Methodology: 88 patients operated on by a podiatric surgeon were asked to complete an anonymous foot surgery satisfaction questionnaire. The same questionnaire was sent to another random selection of 88 orthopaedic patients matched by Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures code (OPCS). Results: Of the 88 questionnaires sent to each group 56 (63.6%) were returned to the (podiatric group) and 60 (68.2%) the (orthopaedic). Patient satisfaction was rated as excellent 63.7%, moderate/good 23.6% and poor 12.7% of podiatric respondents and excellent 43.4%, moderate 17% and poor 39.6% of orthopaedic respondents. Conclusion: The results suggest that patient satisfaction following foot surgery rose significantly following appointment of a podiatric surgeon. Improvements were identified in the overall outcome of the surgery and other aspects of the patients’ journey. To date we are not aware of any study that has reviewed outcomes of an integrated approach and, as such provides a historical benchmark. [Copyright &y& Elsevier]

Abstract: Introduction: In order to ensure we provided an appropriate patient focused service we undertook a prospective audit of referrals to our surgical foot and ankle department in a large District General Hospital/Treatment centre. Methodology: An audit was conducted over a 12 month period to establish the initial referral patterns to a dedicated foot and ankle service. This was undertaken by completion of a dedicated audit form, with departmentally agreed terms and domains following the International coding of diseases (ICD) system. The form was completed by the attending clinician for each new patient contact and the information gathered included referral source; attending clinician; diagnosis; investigations; treatment; and ongoing referral patterns. Results: 1133 referrals were received over a 12-month period. Of these 974 [86%] were referred from their general practitioner. 118 patients had a secondary concern and 12 had a third complaint. For ease, the presenting complaints were clustered under six sub-headings; first ray {426}; lesser rays {324}; rear-foot {111}; tendonopathy/ligament/soft tissue {288}; mid-foot {72}; systemic/general {158}. 775 investigations were requested. These were subdivided into their specific modalities. Treatment included surgery for {65%}; steroid injection {12%}; Orthoses {17.4%}; Advice {13%}; Physiotherapy {3.4%}. Conclusion: Only 65% of GP referrals to this surgical service were deemed appropriate as they progressed directly to surgery. However, it is important to establish what constitutes ‘appropriate’ since within the remaining 35% of referrals only 66 (5.8%) required no intervention at all. Of the residual group who required ‘treatment’ approximately 17% required steroid injection or orthoses and 143 (13%) received advice and went away to contemplate the consultation. Referral pathways could be improved by greater communication between GP and foot and ankle service with the construction and implementation of referral guidelines which would enhance the referral and treatment pathway to the service. [Copyright &y& Elsevier]

Abstract: Study Objective: The objectives of the present study were to describe the incidence of low anti-Xa levels defined as below 0.1 IU/mL in a general surgical intensive care unit population and to evaluate factors independently influencing anti-Xa activity. Design: A prospective study was undertaken. Setting: Thirty-six patients admitted to a general intensive care unit and receiving subcutaneous (SC) enoxaparin 30 mg twice daily for thromboprophylaxis between November 2003 and August 2005 were included in the study. Measurements and Main Results: After reaching steady state, anti-Xa activity was determined by chromogenic assay at 0, 3, 6, and 9 hours after injection. Anti-Xa levels below 0.1 IU/mL at any time were considered subtherapeutic. Areas under the curve (AUCs) for a 12-hour dosing interval were estimated. Factors influencing anti-Xa AUC were evaluated using linear regression. Two patients (5.6%) did not attain therapeutic levels defined as anti-Xa more than 0.1 IU/mL at 3 hours post dose. Median AUC was 1.84 IU·h/mL (interquartile range, 1.47 IU·h/mL). In the linear regression analysis, sex and creatinine clearance were significant predictors of anti-Xa AUC0-12h levels. Conclusion: In the study, prophylactic SC enoxaparin in critically ill patients at the current 30 mg SC twice daily dosage attained an anti-Xa level more than 0.1 U/mL in nearly all patients. In addition, low creatinine clearances and female sex are associated with higher anti-Xa activity AUC0-12h. [Copyright &y& Elsevier]

Abstract: Background: Heparin-induced thrombocytopenia (HIT) is commonly considered but rarely confirmed in critically ill patients. The 4Ts score (Thrombocytopenia, Timing of thrombocytopenia, Thrombosis, and oTher reason) might identify individual patients at risk of having this disorder. Objective: The aim of the study was to evaluate the value of the 4Ts HIT score in comparison with the serotonin-release assay (SRA) in critically ill patients. Methods: This study describes the combined results of 3 prospective studies enrolling critically ill patients who were investigated for HIT if platelets fell to less than 50 × 109/L or if platelet counts decreased to less than 50% of the value upon intensive care unit admission. We confirmed HIT by a positive platelet SRA. We assigned a 4Ts score blinded to SRA results to all 50 patients investigated for HIT; those with positive SRA results were scored in duplicate. Results: Of 528 patients, 50 (9.5%) were investigated for HIT; 39 (78%) of 50 (64%-88%) of these patients were scored as “low probability” by 4Ts score and none had a positive SRA. Of 49 patients who underwent SRA testing because of thrombocytopenia, only 2 (4.1%; 0.5-14.0) had a positive SRA (1 with a moderate 4Ts score and 1 with a high 4Ts score). Therefore, the overall incidence of HIT confirmed by SRA was 2 (0.4%) of 528 (0.04%-1.4%). Conclusions: Significant thrombocytopenia during heparin administration occurred in 9.5% of critically ill patients, but HIT was confirmed in only 4.1% of those undergoing testing, for an overall incidence of 0.4%. A low 4Ts score occurred in 78% of patients investigated for HIT; none of these patients had a positive SRA. We conclude that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population. [Copyright &y& Elsevier]

Abstract: To examine the effects of acute altitude-induced hypoxia on the hormonal and metabolic response to ingested glucose, 8 young, healthy subjects (5 men and 3 women; age, 26 ± 2 years; body mass index, 23.1 ± 1.0 kg/m2) performed 2 randomized trials in a hypobaric chamber where a 75-g glucose solution was ingested under simulated altitude (ALT, 4300 m) or ambient (AMB, 362 m) conditions. Plasma glucose, insulin, C-peptide, epinephrine, leptin, and lactate concentrations were measured at baseline and 30, 60, 90, and 120 minutes after glucose ingestion during both trials. Compared with AMB, the plasma glucose response to glucose ingestion was reduced during the ALT trial (P = .04). There were no differences in the insulin and C-peptide responses between trials or in insulin sensitivity based on the homeostasis model assessment of insulin resistance. Epinephrine and lactate were both elevated during the ALT trial (P < .05), whereas the plasma leptin response was reduced compared with AMB (P < .05). The data suggest that the plasma glucose response is suppressed at ALT, but this is not due to insulin per se because insulin and C-peptide levels were similar for both trials. Elevated plasma epinephrine and lactate during ALT are indicative of increased glycogenolysis, which may have masked the magnitude of the reduced glucose response. We conclude that, during acute altitude exposure, there is a rapid metabolic response that is accompanied by a shift in the hormonal milieu that appears to favor increased glucose utilization. [Copyright &y& Elsevier]

Abstract: Allocating scarce resources for dysglycemia intervention requires identification of persons who will benefit. Identification has two steps: screening followed by diagnosis. Lowering a screening test''s cut-off score identifies more persons with dysglycemia, but causes more normoglycemic persons to receive diagnostic testing. Raising a test''s cut-off score reduces needless diagnostic testing, but increases the number falsely identified as not having dysglycemia. With limited budgets for intervention, raising a screening test''s cut-off score may be appropriate. With ample budgets, lowering the test''s cut-off score may be appropriate. Screening tests are most efficient in populations with high prevalence of dysglycemia. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to determine whether the use of gastric acid-suppressive agents increases the risk of nosocomial pneumonia (NP) in a medical intensive care unit population. Materials and Methods: Retrospective cohort study in a medical intensive care unit of a 554-bed, university-affiliated, academic medical center. Results: A total of 924 medical records were included in the database during the study period of which 787 patients were included in the study. Out of this cohort,104 patients (13.2%) eventually developed a NP. The risk for patients who received proton-pump inhibitors (adjusted hazard ratio [AHR] 0.63; 95% CI 0.39-1.01) was not significantly different than in non exposed patients. Variables most strongly associated with NP were the administration of sedatives or neuromuscular blockers for at least 2 consecutive days (AHR 3.39;95% CI 1.99-5.75), an Acute Physiology and Chronic Health Evaluation II (APACHE II) severity score greater than 15 (AHR, 3.34; 95% CI 1.82-6.50), and presence of a central venous catheter (AHR, 1.76; 95% CI 1.12-2.76). Conclusions: Prior use of a proton-pump inhibitor did not correlate with a significant increase in the risk of developing NP. This risk was higher with the administration of sedatives or neuromuscular blockers, increased disease severity, and placement of a central venous catheter. [Copyright &y& Elsevier]

Abstract: Purpose: Clinical uncertainty exists regarding the significance of colonization confined to respiratory tract secretions with Candida sp in critically ill patients. Our objectives were to describe such colonization, its associated risk factors, and to examine the clinical outcomes in patients with a clinical suspicion of ventilator-associated pneumonia with isolated Candida colonization compared to those without. Materials and Methods: In a retrospective analysis of the Canadian ventilator-associated pneumonia study, patients were divided into 2 groups according to the isolated presence or absence of Candida in the respiratory tract enrollment culture. We compared length of mechanical ventilation, intensive care unit and hospital stay, and mortality outcomes between groups. We used multiple logistic regression analysis to determine factors independently associated with Candida colonization and hospital mortality. Results: Of the 639 eligible patients, 114 (17.8%) were colonized with Candida in the enrollment culture. A multivariate analysis identified female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.02-2.65), number of comorbidities (OR, 1.35; 95% CI, 1.08-1.71), worsening or persistent infiltrate at randomization (OR, 1.92; 95% CI, 1.09-1.38), antibiotics started within 3 days of randomization (OR, 3.16; 95% CI, 1.71-5.83), and on antibiotics at randomization but all started more than 3 days before randomization (OR, 3.04; 95% CI, 1.68-5.50) as variables associated with Candida respiratory tract colonization. A significant increase in median hospital stay (59.9 vs 38.6 days, P = .006) and hospital mortality (34.2% vs 21.0%, P = .003) was observed in patients with Candida colonization. In a multivariate model, Candida colonization of the respiratory tract was independently associated with hospital mortality (OR, 2.47; 95% CI, 1.39-4.37). Conclusion: Respiratory tract Candida colonization is associated with worse clinical outcomes and is independently associated with increased hospital mortality. However, it is unclear whether Candida colonization is causally related to poor outcomes or whether it is a marker for increased morbidity and mortality. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of the study was to describe the epidemiology and management of atrial fibrillation (AF) in noncardiac surgery critically ill patients in a retrospective, observational study at 3 mixed medical-surgical, university-affiliated intensive care units (ICUs). Methods: Consecutive patients admitted during a 1-year period with any documentation of AF during ICU stay were identified. Demographic data, risk factors, interventions, and outcomes were collected from the medical record. Results: A total of 3081 patients were admitted during the 1-year study period in which 348 consecutive patients (10.5%) had documented AF. Atrial fibrillation was of new onset in 139 patients (4.5%) and preexisting in 186 patients (6.0%). Hemodynamic instability developed in 37% and 10% of patients with new-onset AF and patients with preexisting AF, respectively. Most (73%) patients with new-onset AF had at least 1 modifiable risk factor. Pharmacologic rhythm conversion was attempted in 76% and 26% of patients with new-onset AF and patients with preexisting AF, respectively. Although initially successful in 87% of new-onset cases, 42% reverted back to AF. Electrical conversion was successful in 7 (27%) of 26 and 0 (0%) of 5 of patients with new-onset AF and patients with preexisting AF, respectively. In total, 18% and 62% of patients with new-onset AF and patients with preexisting AF, respectively, who survived to ICU discharge left the ICU in AF. Conclusions: Atrial fibrillation is common but transient in most ICU patients. Electrical cardioversion is often unsuccessful, and pharmacologic rhythm conversion is often only transiently effective. Modifiable risk factors are common among these patients. Future studies are needed to address the management of AF in the ICU. [Copyright &y& Elsevier]

There is now strong evidence that lifestyle modification can prevent or delay the development of type 2 diabetes mellitus in high-risk individuals. Women with gestational diabetes mellitus are at increased risk for type 2 diabetes and so are candidates for prevention programs. We review literature on type 2 diabetes risk in women with gestational diabetes, examine current recommendations for postpartum and long-term follow-up, and summarize findings from a 2007 expert-panel meeting. We found data to support that women with gestational diabetes have an increase in risk of type 2 diabetes comparable in magnitude with that of individuals with impaired glucose tolerance and/or impaired fasting glucose and that prevention interventions likely are effective in this population. Current recommendations from leading organizations on follow-up of women after delivery are conflicting and compliance is poor. Clinicians and public health workers face numerous challenges in developing intervention strategies for this population. Translation research will be critical in addressing this important public health issue. [Copyright &y& Elsevier]