Shorter Duration Of Use Research Articles

Risk of fracture in patients with non-valvular atrial fibrillation initiating direct oral anticoagulants vs. vitamin K antagonists.

To determine the risk of fracture associated with direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF), accounting for cumulative duration of use. Using Quebec administrative healthcare databases, we formed a cohort of all patients aged 40 years or older newly diagnosed with NVAF, who filled a first prescription for DOACs or VKAs between 2011 and 2014. Exposure was modelled as a time-varying variable whereby patients were considered unexposed up to 180 days of cumulative duration of use (to account for a biologically meaningful exposure) and exposed thereafter. The final cohort included 10306 new users of DOACs and 15357 new users of VKAs. After propensity score-based fine stratification and weighting, use of DOACs for 180 days or greater was associated with a 35% decreased risk of fracture [crude incidence rates 7.5 vs. 15.3 per 1000 person-years; adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.46-0.91] compared to VKA duration ≥180 days. Direct oral anticoagulants use was also associated with a lower risk of hip fracture (HR 0.51, 95% CI 0.31-0.86) compared with VKAs. There was no difference in the rate of fracture for shorter duration of use (HR 1.10; 95% CI 0.79-1.53). The risk was not modified by age, sex, chronic kidney disease, osteoporosis, history of fracture or falls. Prolonged use of DOACs is associated with a lower risk of fracture compared with VKAs. These findings support the first-line recommendation for DOACs in patients with NVAF.

Narcotic Consumption in Opioid-Naïve Patients Undergoing Total Hip and Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to total hip arthroplasty (THA). This study aims to compare acute postoperative narcotic consumption between the 2 procedures and quantify amount of narcotics used by opioid prescribed. MethodsFrom October 2017 to August 2019, patients were surveyed at 4-week follow-up to determine amount and duration of opioids used and whether they continued to require narcotics. Among 1332 patients who self-identified as opioid naïve, 670 underwent THA and 662 underwent TKA. Descriptive analysis was performed based on data type. ResultsThe total morphine equivalent dose (MED) used in the postoperative period was lower in THA than in TKA (143 ± 160 vs 259 ± 250 MED, P < .001). The duration of use was shorter, total amount of pills consumed was lower, and refill rates were less in THA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics at 4-week follow-up in THA compared to TKA. A postoperative prescription of 45 pills of any one type of narcotic was sufficient for nearly 90% of THA patients, and 60 pills of any one type of narcotic was appropriate for over 75% of TKA patients. ConclusionTHA is associated with less total narcotic consumption, shorter duration of use, less refills, and lower likelihood of requiring narcotics at 4-week follow-up. Percentiles of total narcotics consumed are provided to promote judicious postoperative prescribing patterns, and one could consider further reducing narcotics when utilizing our protocol, particularly for THA patients. Level of EvidenceThis is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid-naïve patients undergoing total hip and knee arthroplasty.

Factors associated with long-term pessary use

Vaginal pessary is a well-established pelvic organ prolapse (POP) treatment, but little evidence about long-term use is available. Our aim was to report the duration of use and investigate predictors of long-term pessary use for POP. We hypothesized that younger, healthier women and women who experienced complications would have shorter duration of use.

Electronic cigarette use among Italian smokers: patterns, settings, and adverse events.

Information is scanty on the patterns and settings of electronic cigarette use and on its possible adverse events. To fill the knowledge gap on these issues, we conducted a survey among ever-smokers attending smoking cessation services (SCS) in Italy. In 2016-2018, we enrolled 395 ever-smokers aged ⩾18 years who were current or former electronic cigarette users in 12 SCS from northern, central, and southern Italy. In all, 12.4% of ever smokers were regular, 9.4% occasional, and 78.2% past users of electronic cigarettes. Of all users, 93.8% consumed electronic cigarettes with nicotine, 95.9% used refillable devices, and 76.6% purchased electronic cigarette devices or liquids in vape shops. The mean duration of use was 3.7 months and the mean number of puffs per day was 86. Among users, 71.5% used electronic cigarettes in at least 1 smoke-free indoor environment, 53.7% in workplaces, 49.5% in restaurants and bars, 33.5% in train/metro stations or airports, and 18.4% in public transports. The use of electronic cigarettes in smoke-free environments significantly decreased with age and increased with duration of use and nicotine dependence. In our sample, 47.1% reported at least 1 adverse event attributable to electronic cigarette use: 19.5% dry cough, 12.0% dry mouth, 7.6% throat or mouth irritation, and 6.8% sore throat. In Italy, most conventional cigarette smokers use electronic cigarettes where smoking conventional cigarettes is prohibited. About half of users reported 1 or more symptoms attributable to electronic cigarettes, despite the relatively short duration of use.

Narcotic Consumption in Opioid Naïve Patients Undergoing Unicompartmental and Total Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to unicompartmental knee arthroplasty (UKA). The purpose of the current study is to compare acute postoperative narcotic consumption between the 2 procedures and quantify narcotic consumption. MethodsFrom October 2017 to August 2019 patients were surveyed for four weeks to determine the amount and duration of opioids consumed and requirement for continued narcotics. Among 976 opioid naïve patients, 314 (32%) underwent UKA and 662 (68%) underwent TKA. Patients were analyzed according to specific narcotic prescribed. Total morphine equivalent dose (MED), number of pills, duration, refill percentage, and usage percentage for 4 weeks were calculated for each procedure. ResultsMED used in the postoperative period was lower in patients undergoing UKA than TKA (200 ± 195 vs 259 ± 250 MED, P = .002). Total number of pills consumed and duration of use was less in UKA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics for 4 weeks after UKA (32% vs 43%, P < .001), and fewer UKA patients required narcotic refills (14% vs 27%, P < .001). Sixty pills of any 1 type of narcotic was sufficient for 90% of UKA patients and over 75% of TKA patients. ConclusionUKA is associated with less narcotic consumption, shorter duration of use, less refills, and lower likelihood of narcotic requirement for 4 weeks. We report narcotic consumption patterns for both procedures to aid surgeons in judicious postoperative prescribing. Level of EvidenceThis is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid naïve patients undergoing UKA or TKA.

Surveillance of Opioid Prescribing as a Public Health Intervention: Washington State Bree Collaborative Opioid Metrics.

Context:To address risks associated with prescription opioid medications, guidelines recommend lower dose, shorter duration of use, and avoidance of concurrent sedatives. Monitoring opioid-prescribing practices is critical for assessing guideline impact, comparing populations, and targeting interventions to reduce risks.Objective:To describe development of Washington (WA) State opioid-prescribing metrics, provide purpose and definitions, and apply metrics to prescription data for WA health care organizations.Design:We describe the development and testing of opioid-prescribing metrics by the WA State Bree Collaborative opioid work group.Setting:Washington State.Participants:Kaiser Permanente of Washington (KPW) Integrated Group Practice, KPW-contracted care providers, and WA Medicaid.Main Outcome Measures:Set of 6 strategic metrics tested across 3 different health systems adopted by WA State in 2017 for uniform tracking of opioid-prescribing guidelines and state policies. These metrics include (1) overall prevalence of any opioid use, (2) chronic use, (3) high-dose chronic use, (4) concurrent chronic sedative use, (5) days' supply of new prescriptions, and (6) transition from acute to chronic use.Results:In the first quarter of 2010, 10% to 12% of KPW and 14% of Medicaid patients received at least 1 opioid prescription. Among opioid users, 22% to 24% of KPW and 36% of Medicaid patients received chronic opioids. Among patients receiving chronic opioids, 16% to 22% of KPW and 32% of Medicaid patients received high doses (≥90 morphine-equivalent dose per day) and 20% to 23% of KPW and 33% of Medicaid patients received concurrent chronic sedatives. Five percent of Medicaid and 2% to 3% of KPW patients receiving new opioid prescriptions transitioned to chronic opioid use.Conclusions:The metrics are relatively easy to calculate from electronic health care data and yield meaningful comparisons between populations or health plans. These metrics can be used to display trends over time and to evaluate the impact of opioid-prescribing policy interventions.

The renin-angiotensin aldosterone system and osteoporosis: findings from the Women's Health Initiative.

Pharmacological inhibitors of the renin-angiotensin aldosterone system (RAAS) are used to treat hypertension. However, the relationship of these medications to osteoporosis is inconsistent, and no study has included simultaneous measurements of both incident fractures and bone mineral density (BMD). The association of RAAS inhibitor use (n = 131,793) with incident fractures in new users of these medications in women in the Women's Health Initiative over a minimum median follow-up of 6.5years was assessed by Cox proportional hazard models. The association of incident fractures by a cumulative duration of use of these medications (<3years.) and (> 3years.) was also estimated. Subgroup analysis of fracture risk by RAAS inhibitor use confined to women with hypertension was also performed (n = 33,820). The association of RAAS inhibitor use with changes in BMD of the hip was estimated by linear regression in 8940 women with dual energy X-ray absorptiometry measurements. There was no significant association between RAAS inhibitor use and all fractures in the final adjusted multivariable models including hip BMD (HR 0.86 (0.59, 1.24)). However, among users of RAAS inhibitors, including ACE inhibitors and angiotensin receptor blockers (ARBs), hazard ratios for all incident fracture sites in final multivariable models including hip BMD showed dramatic differences by duration of use, with short duration of use (3years or less) associated with a marked increased risk for fracture (HR 3.28 (1.66, 6.48)) to (HR 6.23 (3.11, 12.46)) and use for more than 3years associated with a reduced fracture risk (HR 0.40 (0.24, 0.68) to (HR 0.44 (0.20, 0.97)) . Findings were similar in the subgroup of women with a history of hypertension. There was no significant change in BMD of the hip by RAAS inhibitor use. In postmenopausal women, use of RAAS inhibitors, including ACE inhibitors and ARBs, is associated with an increased risk for fracture among new users of these medications in the first 3years of use. However, long-term use (> 3years) is associated with a reduced risk. Consideration for fracture risk may be part of the decision-making process for initiation of these medications for other disease states.

Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study

ObjectiveElectronic cigarettes (e-cigarettes) which utilise prefilled ‘pods’ (pod devices) entered the US market in 2015. One brand, JUUL, captured more than half the e-cigarette market in early 2018, and the...

Skin exposure to the rubber accelerator diphenylguanidine in medical gloves-An experimental study.

Dermatitis caused by occupational contact allergy to rubber additives such as diphenylguanidine (DPG) in medical gloves is a hazard for healthcare workers. Both the duration of exposure to medical gloves and the number of gloves used per day vary. The use of alcoholic skin disinfectants before glove donning is mandatory. To assess whether skin exposure to the rubber accelerator DPG released from glove material is influenced by alcoholic hand disinfectants, time, and pH. With the use of ethanol washes, the amount of DPG left on the hands after wearing of gloves for 60 minutes was measured, and comparisons between hands exposed and not exposed to alcoholic disinfectant before glove donning were made. With the use of artificial sweat buffered at pH 4, 5, and 6, DPG release from the insides of gloves at different times was measured. The use of alcoholic disinfectant prior to polyisoprene glove donning increased the amount of DPG recovered from the hands. Of the DPG released from polyisoprene gloves into artificial sweat, almost 84% was released within 10 minutes. pH did not influence the rate of release. The use of alcoholic disinfectant increased skin exposure to the rubber accelerator DPG. Even a short duration of use of gloves results in substantial exposure to DPG.

A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions.

Context:Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics.Aims:We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics.Subjects and Methods:Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi.Statistical Analysis Used:Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient.Results:The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01).Conclusions:Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.

Opioid-free colorectal surgery: a method to improve patient & financial outcomes in surgery.

Opioids are a mainstay for postsurgical pain management, but have associated complications and costs, and contribute to the opioid epidemic. While efforts to reduce opioid use exist, little study has been done on opioid utilization and its impact across surgical approaches. Our goal was to evaluate the impact of opioid utilization on quality measures and costs after open and laparoscopic colorectal surgery. The Premier database was reviewed for inpatient colorectal procedures from January 01, 2014, to September 30, 2015. Procedures were stratified into open and laparoscopic approaches, then "opioid" and "opioid-free" groups within each approach. Univariate analysis compared demographics, outcomes, and cost by opioid use and surgical approach. In the "opioid" groups, opioid consumption and duration were assessed across platforms. Multivariate regression analyzed the association between opioid use and surgical approach on costs and quality outcomes. 50,098 procedures were evaluated-40.4% laparoscopic and 59.6% open. 6.6% of laparoscopic and 5.3% of open cases were "opioid free." Across both approaches, patients over 65 were most likely opioid free, while the obese and cancer patients were most likely to use opioids. Length of stay was shorter, and post-discharge nursing needs and total costs were lower in the "opioid-free" group in both approaches (all p < 0.001). The median daily and total opioid consumption were lower with a laparoscopic approach (p < 0.001), which also had a shorter duration of use versus open cases (p < 0.001). Opioids were 20% more likely in open cases. Total costs were 16% greater with opioids and 24% greater in open surgery. Complications were 89% more likely in open surgery. Readmissions were increased by 14% with both opioid use and open surgery. Opioid-free colorectal surgery results in improved outcomes, and laparoscopy further improves these results. Continued efforts to increase laparoscopy are key for reducing opioids and improving outcomes as we transition to value-based care.

Active heat pulse sensing of 3-D-flow fields in streambeds

Abstract. Profiles of temperature time series are commonly used to determine hyporheic flow patterns and hydraulic dynamics in the streambed sediments. Although hyporheic flows are 3-D, past research has focused on determining the magnitude of the vertical flow component and how this varies spatially. This study used a portable 56-sensor, 3-D temperature array with three heat pulse sources to measure the flow direction and magnitude up to 200 mm below the water–sediment interface. Short, 1 min heat pulses were injected at one of the three heat sources and the temperature response was monitored over a period of 30 min. Breakthrough curves from each of the sensors were analysed using a heat transport equation. Parameter estimation and uncertainty analysis was undertaken using the differential evolution adaptive metropolis (DREAM) algorithm, an adaption of the Markov chain Monte Carlo method, to estimate the flux and its orientation. Measurements were conducted in the field and in a sand tank under an extensive range of controlled hydraulic conditions to validate the method. The use of short-duration heat pulses provided a rapid, accurate assessment technique for determining dynamic and multi-directional flow patterns in the hyporheic zone and is a basis for improved understanding of biogeochemical processes at the water–streambed interface.

Economic Analysis of Protected Cultivation: Comparison of Vegetable vs. Fruit

This research examines solution to overcome the problems of opposition to growing vegetables under protected cultivation, This particular example was chosen to illustrate several important aspects of greenhouse production and marketing that affect profitability such as high prices of vegetable seeds, high prices of materials used in the sterilisation (methyl bromide gas), high prices of plastics in addition to low quality and short duration of use, etc.The study depended on Bossali protected agriculture unit as example of application to measure the performance and efficiency of production and revenue during the period 1994-2006. Using the traditional system of protected cultivation, compared with a new system of performance and management of production processes, depends on the cultivation of some fruit crops under protected cultivation during the period 2007-2015.The study analysed the structure cost of production per greenhouse also discussed some economic indicators such as: farm gate prices, total revenue, total costs and net return of cucumber and sweet pepper (as example for vegetables) and navel orange and keitt mango (as example for fruits). This enterprise budget illustration indicates a lack of profitability of this greenhouse vegetable enterprise using these particular assumptions regarding cost, price, and total revenue. Results revealed that net return reached 1234, 3466 Egyptian pound (LE)/greenhouse (540 m2) in navel orange and keitt mango respectively during the study period.

Glucosamine use and risk of colorectal cancer: results from the Cancer Prevention Study II Nutrition Cohort.

Use of glucosamine supplements has been associated with reduced risk of colorectal cancer (CRC) in previous studies; however, information on this association remains limited. We examined the association between glucosamine use and CRC risk among 113,067 men and women in the Cancer Prevention Study II Nutrition Cohort. Glucosamine use was first reported in 2001 and updated every 2years thereafter. Participants were followed from 2001 through June of 2011, during which time 1440 cases of CRC occurred. As has been observed in prior studies, current use of glucosamine, modeled using a time-varying exposure, was associated with lower risk of CRC (HR 0.83; 95% CI 0.71-0.97) compared to never use. However, for reasons that are unclear, this reduction in risk was observed for shorter-duration use (HR 0.68; 95% CI 0.52-0.87 for current users with ≤ 2years use) rather than longer-duration use (HR 0.90; 95% CI 0.72-1.13 for current users with 3 to < 6years of use; HR 0.99; 95% CI 0.76-1.29 for current users with ≥ 6years of use). Further research is needed to better understand the association between glucosamine use and risk of CRC, and how this association may vary by duration of use.

Increasing Bending Stiffness of Antibiotic-impregnated Cement-covered Rod Constructs: A Biomechanical Study

Introduction: The use of antibiotic-impregnated cement-covered rods (ACR) has been reported for the treatment of posttraumatic osteomyelitis and infection. Early reports of ACRs described using a 3-mm guidewire as the central core of the rod; however, certain clinical scenarios may require a more rigid construct. We describe the principals and technique of using a thicker metal core to increase stiffness of the ACR. A 40-Fr chest tube was filled with polymethyl methacrylate (PMMA) cement. Metal central rods (3 and 5.8 mm) were inserted before the cement cured. Bending stiffness was measured and compared with a conventional intramedullary nail. Increasing the core diameter of ACR constructs resulted in increased bending stiffness, but the ACR remained significantly weaker than conventional nails. Given the elution characteristics of antibiotic cement, and the relatively short duration of use of these rods, the relative decrease in volume of cement is unlikely to influence antibacterial effectiveness of the ACR. Purpose: The use of ACRs has been reported for the treatment of posttraumatic osteomyelitis and infection. Early reports of antibiotic rods described using a 3-mm guidewire as the central core of the rod; however, certain clinical scenarios may require a more rigid construct. The purpose of this study was to examine the use of a thicker metal core to increase stiffness of the ACR construct. Methods: A 40-Fr chest tube was filled with PMMA cement and metal central rods were inserted before the cement cured. Central cores utilized were a 3-mm intramedullary guidewire and a 5.8-mm fully threaded ring external fixator strut. Bending stiffness was then measured along multiple lengths of each specimen and compared with the bending stiffness of the bare metal inserts (without cement) and a conventional intramedullary nail (10.5-mm titanium). Results: The mean bending stiffness was 4.96±0.67 N m2 for the 5.8-mm-core cement rod and 3.07±0.28 N m2 for the 3-mm-core cement rod (P=0.0039). The bending stiffness for the 3-mm guidewire, 5.8-mm rod, and the intramedullary nail alone were 0.87, 3.1, and 31.7 N m2, respectively. Conclusions: Increasing core diameter of ACR constructs will predictably increase their bending stiffness; however, ACRs will remain significantly weaker than conventional intramedullary nails. Given the elution characteristics of antibiotic cement, and the relatively short duration of use of these rods, the relative decrease in volume of cement is unlikely to influence the antibacterial effectiveness of the ACR.

Systematic Review of the Topical Steroid Addiction and Topical Steroid Withdrawal Phenomenon in Children Diagnosed With Atopic Dermatitis and Treated With Topical Corticosteroids

ABSTRACT Background A 2015 National Eczema Association study concluded that topical steroid withdrawal is an effect of prolonged, frequent use of topical steroids occurring mostly in adult women. It is unclear whether children develop topical steroid withdrawal. Objective The aim of this study was to assess current evidence regarding topical steroid withdrawal in children. Methods This study is a systematic review of medical literature as well as online social media sites and blogs regarding topical steroid withdrawal in children. Results Literature search yielded zero studies on/or reporting classic topical steroid withdrawal in children; however, periorificial dermatitis, which is generally a steroid-induced disorder in children, was reported in &gt;320 cases. Of 142 social media blogs on topical steroid withdrawal, 26 were blogs discussing children. Twenty-seven cases were included in this review. Length of topical steroid use ranged from 2 months to 12 years. Conclusions Topical steroid withdrawal occurs in children and can result from discontinuing topical steroids used for as little as 2 months. Resultant signs/symptoms can last &gt;12 months, even with short duration of use. Clinicians and caregivers should be aware of this possible adverse effect of topical steroids and monitor the effects of topical steroids on infants/children, but more data are needed on this condition.

Traditional suburethral sling operations for urinary incontinence in women.

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence. To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options. We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles. Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence. At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data. We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out. Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

The Vacuum Bell device as a sternal lifter: An immediate effect even with a short time use

BackgroundTo minimize cardiac perforation during the minimally invasive repair of pectus excavatum (MIRPE), several surgeons have suggested using a suction device to intraoperatively lift the sternum. Whether or not this technique is effective for all PE patients is not yet known. As such, our aim was to quantify the extent to which a suction device is capable of lifting the sternum with a short duration of use. Methods30 PE patients received a low-dose CT scan as part of standard PE evaluation. A Vacuum Bell suction was then applied for only two minutes, and a repeat CT scan was obtained only at the deepest point of the chest wall deformity. We compared chest dimensions before and after Vacuum Bell suction. ResultsThe Vacuum Bell lifted the sternum in all 29 patients included in the analysis. The absolute change in depth ranged from 0.29 to 23.67mm (M=11.02, SD=6.05). The average improvement in Haller index was 0.76. The suction was most effective for individuals with low BMI and smaller chest depths. Efficacy was not associated with gender, age, or chest morphology. ConclusionsThe Vacuum Bell device effectively lifted the sternum in PE patients with different demographics and chest morphologies. Future research is needed to address whether or not the device reduces risk of cardiac perforation during MIRPE. Levels of evidencePrognosis Study Level IV.

Stone Dead: Uncovering Early Mesolithic Mortuary Rites, Hermitage, Ireland

In Europe, cremation as a burial practice is often associated with the Bronze Age, but examples of cremated human remains are in fact known from the Palaeolithic onwards. Unlike conventional inhumation, cremation destroys most of the evidence we can use to reconstruct the biography of the buried individual. Remarkably, in Ireland, cremation is used for the earliest recorded human burial and grave assemblage (7530–7320 bc) located on the banks of the River Shannon, at Hermitage, County Limerick. While we are unable to reconstruct in any great detail the biography of this individual, we have examined the biography of a polished stone adzehead interred with their remains. To our knowledge, this adze represents the earliest securely dated polished axe or adze in Europe. Microscopic analysis reveals that the adze was commissioned for burial, with a short duration of use indicating its employment in funerary rites. Before its deposition into the grave it was intentionally blunted, effectively ending its use-life: analogous to the death of the individual it accompanied. The microwear traces on this adze thus provide a rare insight into early Mesolithic hunter-gatherer belief systems surrounding death, whereby tools played an integral part in mortuary rites and were seen as fundamental pieces of equipment for a successful afterlife.

Mortality Risk of Antipsychotic Dose and Duration in Nursing Home Residents with Chronic or Acute Indications.

To examine disease-specific associations between antipsychotic dose and duration and all-cause mortality. Retrospective cohort study. A 5% random sample of Medicare beneficiaries who had a Minimum Data Set 2.0 clinical assessment completed between 2007 and 2009. Three mutually exclusive cohorts of new antipsychotic users with evidence of severe mental illness (SMI, n=5,621); dementia with behavioral symptoms (dementia+behavior) without SMI (n=1,090); or delirium only without SMI or dementia+behavior (n=2,100) were identified. Dose and duration of therapy with antipsychotics were assessed monthly with a 6-month look-back. Dose was measured as modified standardized daily dose (mSDD), with a mSDD of 1 or less considered below or at recommended maximum geriatric dose. Duration was categorized as 30 or fewer, 31 to 60, 61 to 90, and 91 to 184days for SMI and dementia+behavior and 7 or fewer, 8 to 30, 31 to 90, and 91 to 184days for delirium. Complementary log-log models with mSDD and duration as time-dependent variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. In all three groups, new antipsychotic users with a mSDD of 1 or less had significantly lower mortality risk (HRSMI =0.77, 95% CI=0.67-0.88; HRdementia+behavior = 0.52, 95% CI=0.36-0.76; HRdelirium =0.61, 95% CI=0.44-0.85) than peers with a mSDD greater than 1. Individuals with longer duration of antipsychotic use (91-184days for SMI and delirium) had significantly lower mortality than those with a short duration of use (≤30days for SMI; ≤7days for delirium). The interaction between dose and duration was statistically significant in the SMI cohort (P<.001). Lower mortality was observed with within-recommended dose ranges for dementia+behavior, SMI, and delirium and with long duration of antipsychotic use for the latter two disease groups. Prescribers should monitor antipsychotic dosage throughout the course of antipsychotic treatment and customize dose and duration regimens to an individual's indications.