Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States

Background Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery. Methods The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population. Results Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume). Conclusion State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic. Levels of Evidence: Level III: Retrospective, prognostic cohort study

Effect of the detonation-spraying mode on the tribological properties of NiCr-Al2O3 coatings

The article presents the study results of detonation spraying parameters on the phase composition and tribological properties of NiCr-Al2O3 powder coatings. The spraying was carried out at a ratio of the acetylene-oxygen mixture O2 /C2H2=1.856. The detonation barrel filling volume with an explosive gas mixture varied from 30% to 68%. It is determined that the phase composition of the NiCr-Al2O3 coatings varies depending on the degree of detonation barrel filling. With an increase in the detonation barrel’s filling volume, the intensity of the NiCr diffraction peaks is decreased, and the intensity of the a-Al2O3 reflexes is increased, which indicates an increase in the content of the Al2O3 phase. When low filling volume, there is determined a low coating density and uneven roughness. The tribological test results showed that with an increase in the detonation barrel filling volume, there is a decrease in the wear volume, which confirms the increase in the coatings wear resistance. Determined that the lowest friction coefficient was recorded in the sample obtained at the barrel filling volume 68%. The coatings’ high wear resistance is associated with an increase in the alpha phase volume fraction of a-Al2O3 and coatings density.

Structural Features and Tribological Properties of Detonation Gun Sprayed Ti–Si–C Coating

The paper considers the research results of structural-phase state and tribological characteristics of detonation coatings based on Ti–Si–C, obtained at different filling volumes of the explosive gas mixture barrel of a detonation gun. The results analysis indicates that the phase composition and properties of detonation coatings strongly depend on the technological parameters of spraying. With an increase of the explosive mixture in the filling volume of the detonation barrel up to 70% of the coatings consist mainly of the TiC phase, because high temperature leads to a strong decomposition of Ti3SiC2 powders. Thus, the XRD results confirm that at 70% of the explosive gas mixture’s filling volume, partial decomposition and disintegration of the powders occurs after detonation spraying. We established that detonation coatings based on titanium carbosilicide obtained at the explosive gas mixture’s filling volume at 60% are characterized by high wear resistance and adhesive strength. Thermal annealing was performed after spraying in the temperature range of 700–900 °C for 1 h to reduce microstructural defects and improve the Ti–Si–C coating characteristics. As a result of the heat treatment in the Ti–Si–C system at 800 °C, we observed that an increase in the volume fraction of the Ti3SiC2 and TiO2 phases led to a 2-fold increase in microhardness. This means that the after-heat-treatment can provide a sufficient reaction time for the incomplete reaction of the Ti–Si–C (TSC) coating during the detonation gun spraying. Thus, annealing can provide an equal distribution of elements in the coatings.

Collagen Cross‐Linking Is Associated With Cardiac Remodeling in Hypertrophic Obstructive Cardiomyopathy

Background Collagen cross‐linking is covalent bonds among collagen fibers from catalysis of lysyl oxidase (LOX) and advanced glycation end products (AGEs). We aimed to evaluate the formation of enzymatic and nonenzymatic collagen cross‐linking and its clinical significance in patients with hypertrophic obstructive cardiomyopathy. Methods and Results Forty‐four patients with hypertrophic obstructive cardiomyopathy who underwent surgical myectomy were consecutively enrolled. Cardiovascular magnetic resonance parameters of left atrial/left ventricular function were measured, including peak filling rate (PFR) and early peak emptying rate (PER‐E). Total collagen was the sum of soluble and insoluble collagen, which were assessed by collagen assay. The myocardial LOX and AGEs expression were measured by molecular and biochemical methods. Compared with patients without atrial fibrillation, insoluble collagen ( P =0.018), insoluble collagen fraction ( P =0.017), and AGEs ( P =0.039) were higher in patients with atrial fibrillation, whereas LOX expression was similar ( P =0.494). The insoluble collagen fraction was correlated with PFR index (PFR normalized by left ventricular filling volume) (r=−0.44, P =0.005), left atrial diameters (r=0.36, P =0.021) and PER‐E index (PER‐E normalized by left ventricular filling volume) (r=−0.49, P =0.001).Myocardial LOX was positively correlated with total collagen (r=0.37, P =0.025) and insoluble collagen fraction (r=0.53, P < 0.001), but inversely correlated with PFR index (r=−0.43, P =0.006) and PER‐E index (r=−0.35, P =0.027). In multiple regression analysis, myocardial LOX was independently associated with PFR, while insoluble collagen fraction showed independent correlation with PER‐E after adjustment for clinical confounders. Conclusions Collagen cross‐linking plays an important role on heart remodeling in hypertrophic obstructive cardiomyopathy. Myocardial LOX expression is independently correlated with left ventricular stiffness, while accumulation of AGEs cross‐links might be associated with the occurrence of atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy.

Evaluation of Internal Adaptation and Degree of Porosity of Total Crowns After Cementation

The present study evaluated the marginal fit, the internal filling volume and the degree of porosity in cemented metallic total crowns. Then, 12 metal crowns cast in titanium (Ti) were made on bovine teeth with total preparations and 90° shoulder terminal line. The samples were divided into 4 groups according to the type of cement used and the cementation techniques, 2 groups were used Zinc phosphate (SS White) with the partial insertion of the cementing agent filling the inner crown surface (FP) and total filling (FT), and in the other 2 groups, dual resin cement (RelyX ARC 3M) with the partial insertion of cement (RP) and total insertion (RT) were used. The results showed that cervical marginal fit after cementation was clinically adequate in all groups (<100μm), and for the internal filling volume and porosity were: FP - 99.14% / 0.86%; FT = 98.82% / 1.18%; RP - 97.06% / 2.94% and RT - 97.76% / 2.24%. The statistical analysis was performed by Mann-Whitney test. In conclusion, the two types of cements obtained acceptable values of marginal fit, however, the zinc phosphate cement had better internal fill and lower porosity than the resin cement. Regarding the insertion technique, only the FP and FT groups had a statistically significant difference (p < 0.05) compared to the RP group. Keywords: Fixed Partial Denture. X-Ray Microtomography. Dental Cements. ResumoO presente trabalho avaliou o desajuste marginal, o volume de preenchimento interno e o grau de porosidade em cimentações de coroas totais metálicas. A partir de dentes bovinos com preparos periféricos totais e términos cervicais do tipo ombro de 90º, foram confeccionadas 12 coroas metálicas fundidas em titânio (Ti). As amostras foram divididas em 4 grupos de acordo com o tipo de cimento utilizado e as técnicas de cimentação, dentre estes, em 2 grupos foram usados Fosfato de zinco (SS White) com inserção parcial do agente cimentante preenchendo a superfície interna da coroa (FP) e preenchimento total (FT), e nos outros 2 grupos foram usados Cimento resinoso dual (RelyX ARC 3M) com inserção parcial do cimento (RP) e total (RT). As análises foram feitas por microtomografia computadorizada por raios X. Os resultados mostraram que o desajuste marginal cervical após a cimentação estava adequado clinicamente em todos os grupos (<100µm), e para o volume de preenchimento interno e porosidade foram respectivamente: FP – 99,14%/0,86%; FT – 98,82%/1,18%; RP – 97,06%/2,94% e RT – 97,76%/2,24%. Na análise estatística utilizou-se o teste de Mann-Whitney para amostras independentes. Concluiu-se que os dois tipos de cimentos obtiveram valores aceitáveis de desajuste marginal, contudo o cimento de fosfato de zinco apresentou melhor preenchimento interno e menor porosidade que o cimento resinoso. Em relação à técnica de inserção, apenas os grupos FP e FT tiveram diferença estatística significativa (p<0,05) comparado ao grupo RP. Palavras-chave: Prótese Parcial Fixa. Microtomografia por Raio-X. Cimentos Dentários.

Education of medical personnel optimizes filling volume of blood culture bottles without negatively affecting microbiology testing

Background Anemia is a risk factor for adverse outcomes, which can be aggravated by unnecessary phlebotomies. In blood culture testing, up to 30 ml of blood can be withdrawn per sample, even though most manufacturers recommend blood volumes of 10 ml or less. After assessing the filling volume of blood culture bottles at our institution, we investigated whether an educational intervention could optimize filling volume of blood culture bottles without negatively affecting microbiology testing. Methods We weighed 10,147 blood cultures before and 11,806 blood cultures after a six-month educational intervention, during which employees were trained regarding correct filling volume via lectures, handouts, emails, and posters placed at strategic places. Results Before the educational intervention, only 31% of aerobic and 34% of anaerobic blood cultures were filled correctly with 5–10 ml of blood. The educational intervention increased the percentage of correctly filled bottles to 43% (P < 0.001) for both aerobic and anaerobic samples without negatively affecting results of microbiologic testing. In addition, sample volume was reduced from 11.0 ± 6.5 to 9.4 ± 5.1 ml (P < 0.001) in aerobic bottles and from 10.1 ± 5.6 to 8.8 ± 4.8 ml (P < 0.001) in anaerobic bottles. Conclusion Education of medical personnel is a simple and effective way to reduce iatrogenic blood loss and possibly moderate the extent of phlebotomy-induced anemia.

Relationship between right ventricular diastolic dysfunction, right atrial phasic function and ventricular filling in pulmonary arterial hypertension

Background In pulmonary arterial hypertension (PAH) patients, the right ventricle (RV) stiffens due to hypertrophy, fibrosis and intrinsic (sarcomeric) stiffness. In these patients, end-diastolic elastance (stiffness, Eed) is associated with parameters of disease severity and predicts mortality. However, the effect of RV stiffness on RV filling and the effect of increased filling pressures on right atrial (RA) function remain elusive. Purpose To examine the relationship between RV diastolic stiffness and RA phasic function and the effect of diastolic dysfunction on ventricular filling in PAH patients. Methods Using single-beat pressure-volume analyses we determined Eed in controls (n=31) and baseline, treatment naive PAH patients (63 idiopathic, 9 hereditary and 25 connective tissue disease associated). We also measured RA reservoir, conduit and active strain by tissue tracking on cardiac magnetic resonance images. Furthermore, interventricular dyssynchrony was defined as a right to left difference in time to peak circumferential strain &gt;52ms (97.5th percentile in controls). Results End-diastolic pressure was higher in PAH patients (16±7 mmHg) than in controls (8±4 mmHg; p&lt;0.001). Median Eed in patients was 0.635 mmHg/mL (IQR: 0.40–0.99), while in controls it was 0.20 mmHg/mL (IQR: 0.15–0.24). In comparison with controls, patients had reduced RA reservoir (14.3±5.1% vs. 19.1±4.3%; p&lt;0.001) and conduit strain (−5.6±3.4% vs. −12.4±3.3%; p&lt;0.001), while RA active strain was enhanced (−9.0±4.0% vs. −7.5±2.8%; p=0.019). In patients with a stiff RV (Eed above median), RA conduit strain was worse than in patients with a more compliant RV as illustrated in figure A. However, no correlation between RA active strain and Eed was observed (Spearman rho 0.06; p=0.57). Passive filling time of the RV (end-systole until start of atrial contraction) was shorter in patients than in controls (244±136ms vs. 365±103ms; p&lt;0.001). Higher heart rate and ventricular dyssynchrony are causes of a shorter passive filling time in patients as illustrated in figure B. When comparing patients with short vs. long passive filling time (cutoff median of 220ms), the RV passive filling volume was lower (24±15ml vs. 42±19ml; p&lt;0.001). The active filling volume was slightly higher, although not significantly (25±17ml vs. 19±15ml; p=0.12). Conclusion Stiffening of the RV in PAH patients is accompanied by increased filling pressures and decreased RA conduit strain, while there is no correlation between Eed and RA active strain. Higher heart rate and ventricular dyssynchrony lead to shorter passive filling time of the RV, which in turn leads to lower passive filling volume. In contrast, the active filling volume is preserved in these patients. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Netherlands Organization for Scientific Research

Mixing Performance Analysis of Orbitally Shaken Bioreactors

This study investigated the efficacy of a novel correlation of power input, energy dissipation rate and mixing time as a potential route to identify the orbitally shaken bioreactor (OSB) system. The Buckingham’s π-theorem was used to designate and transform dimensionless Newton numbers with five relevant power input variables. These variables were empirically varied to evaluate the correlation among the dimensionless numbers. The Newton number decreases with the increased shaking frequency and filling volume. Previous work has focused on optimizing the mixing process by evaluating different shaking and agitation mixing methods. We establish a new mixing process and assessable measurement of the mixing time in the OSB. An innovative explanation of mixing time for the thermal method is proposed. The optimal mixing time is independent of the temperature of filled liquid. The dimensionless mixing number remained constant in the turbulent regime and increasing with the increased liquid viscosity and filling volume. Our findings revealed that the observed correlation is a practical tool to figure the power consumption and mixing efficiency as cell cultivation in all OSB scales and is fully validated when scaling–up system.