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Frontiers in Microbiology 2023Viral hepatitis is a major public health concern globally. World health organization aims at eliminating viral hepatitis as a public health threat by 2030. Among the... (Review)
Review
Viral hepatitis is a major public health concern globally. World health organization aims at eliminating viral hepatitis as a public health threat by 2030. Among the hepatitis causing viruses, hepatitis B and C are primarily transmitted via contaminated blood. Hepatitis A and E, which gets transmitted primarily via the feco-oral route, are the leading cause of acute viral hepatitis. Although vaccines are available against some of these viruses, new cases continue to be reported. There is an urgent need to devise a potent yet economical antiviral strategy against the hepatitis-causing viruses (denoted as hepatitis viruses) for achieving global elimination of viral hepatitis. Although zinc was known to mankind for a long time (since before Christ era), it was identified as an element in 1746 and its importance for human health was discovered in 1963 by the pioneering work of Dr. Ananda S. Prasad. A series of follow up studies involving zinc supplementation as a therapy demonstrated zinc as an essential element for humans, leading to establishment of a recommended dietary allowance (RDA) of 15 milligram zinc [United States RDA for zinc]. Being an essential component of many cellular enzymes and transcription factors, zinc is vital for growth and homeostasis of most living organisms, including human. Importantly, several studies indicate potent antiviral activity of zinc. Multiple studies have demonstrated antiviral activity of zinc against viruses that cause hepatitis. This article provides a comprehensive overview of the findings on antiviral activity of zinc against hepatitis viruses, discusses the mechanisms underlying the antiviral properties of zinc and summarizes the prospects of harnessing the therapeutic benefit of zinc supplementation therapy in reducing the disease burden due to viral hepatitis.
PubMed: 37908540
DOI: 10.3389/fmicb.2023.1218654 -
International Journal of Medical... Mar 2022The national increase in opioid use and misuse has become a public health crisis in the U.S. To tackle this crisis, the systematic evaluation and monitoring of opioid...
BACKGROUND
The national increase in opioid use and misuse has become a public health crisis in the U.S. To tackle this crisis, the systematic evaluation and monitoring of opioid prescribing patterns is necessary. Thus, opioid prescriptions from electronic health records (EHRs) must be standardized to morphine milligram equivalent (MME) to facilitate monitoring and surveillance. While most studies report MMEs to describe opioid prescribing patterns, there is a lack of transparency regarding their data pre-processing and conversion processes for replication or comparison purposes.
METHODS
In this work, we developed Opioid2MME, a SQL-based open-source framework, to convert opioid prescriptions to MMEs using EHR prescription data. The MME conversions were validated internally using F-measures through manual chart review; were compared with two existing tools, as MedEx and MedXN; and the framework was tested in an external academic EHR system.
RESULTS
We identified 232,913 prescriptions for 49,060 unique patients in the EHRs, 2008-2019. We manually annotated a sample of prescriptions to assess the performance of the framework. The internal evaluation for medication information extraction achieved F-measures from 0.98 to 1.00 for each piece of the extracted information, outperforming MedEx and MedXN (F-Scores 0.98 and 0.94, respectively). MME values in the internal EHR system obtained a F-measure of 0.97 and identified 3% of the data as outliers and 7% missing values. The MME conversion in the external EHR system obtained 78.3% agreement between the MME values obtained with the development site.
CONCLUSIONS
The results demonstrated that the framework is replicable and capable of converting opioid prescriptions to MMEs across different medical institutions. In summary, this work sets the groundwork for the systematic evaluation and monitoring of opioid prescribing patterns across healthcare systems.
PubMed: 35325663
DOI: 10.1016/j.ijmedinf.2022.104739 -
Cureus Nov 2021Overprescribing by providers is a leading contributor to the opioid crisis. Despite available information regarding the role that physician prescribing plays in the...
INTRODUCTION
Overprescribing by providers is a leading contributor to the opioid crisis. Despite available information regarding the role that physician prescribing plays in the community availability of opioids, guidelines for the management of acute pain remain sparse. This project aims to evaluate opioid prescribing, opioid usage patterns, and postoperative pain control in patients undergoing isolated mid-urethral sling (MUS) placement.
METHODS
Patients who underwent isolated MUS placement from March 19, 2019 through March 19, 2020 were contacted by telephone in May 2020 and asked a series of questions examining opioid usage, postoperative pain, what they did with unused opioids, and whether they had received education on disposal techniques. A chart review was utilized to determine the amount of opioid prescribed, the presence of any operative complications, and medical and demographic characteristics of subjects.
RESULTS
A total of 53 subjects met inclusion criteria, of which 31 participated in a phone interview. Of the 53 subjects, 54.7% received a postoperative opioid prescription, and all but two of these subjects filled their prescription. Of the interviewed subjects, only 66.6% who filled a prescription reported using opioids Fifty percent (n=6) of patients that required oxycodone reported use of four tablets (30 morphine milligram equivalents (MMEs)) or less and used for 1-2 days postoperatively. No patient reported using opioids beyond five days. Only 22.2% reported receiving instruction on opioid disposal, and 16.7% returned unused opioids to a disposal center. 87.1% of subjects rated postoperative pain as "better" or "much better" than expected.
CONCLUSION
Patients undergoing isolated MUS placement require limited amounts of postoperative opioids, if any are needed at all, to achieve satisfactory pain control. Excess prescribed opioids, along with inadequate patient education on proper disposal techniques, may contribute towards opioids that are at risk of diversion for nonmedical use.
PubMed: 34926064
DOI: 10.7759/cureus.19595 -
Arthroplasty Today Dec 2022Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient...
BACKGROUND
Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use.
METHODS
Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test.
RESULTS
The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1 day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions.
CONCLUSIONS
Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.
PubMed: 36325518
DOI: 10.1016/j.artd.2022.09.008 -
Surgery Aug 2021Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused...
BACKGROUND
Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing.
METHODS
Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty.
RESULTS
Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period.
CONCLUSION
A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Analgesics, Opioid; Female; Humans; Male; Middle Aged; Motivation; Pain Management; Pain, Postoperative; Practice Patterns, Physicians'; Prescription Drug Monitoring Programs; Prospective Studies
PubMed: 33676733
DOI: 10.1016/j.surg.2021.01.016 -
Journal of Education & Teaching in... Jul 2022The lecture and infographic are targeted towards Emergency Medicine physicians and residents.
AUDIENCE
The lecture and infographic are targeted towards Emergency Medicine physicians and residents.
INTRODUCTION
Pain is the most common presenting symptom in the emergency department.1 Various classes of medications are used to treat acute and chronic pain. Specifically, opiate medications are often used to relieve moderate to severe pain. About 20% of patients presenting with the chief complaint of non-cancer pain receive an opioid prescription.2 Since there are many different types of opiates, conversion between one opioid to another has provided a great challenge in terms of addressing the balance between adequately controlling patients' pain and preventing serious adverse effects. The lack of a readily available standard opiate equivalent guide and physicians' limited knowledge base about morphine milligram equivalents may contribute to medication errors, insufficient treatment, addiction, and overdose.
EDUCATIONAL OBJECTIVES
The primary aim of this study was to educate residents and attending physicians about opiate equivalent medications, medication metabolism, provide usual dosages, and to provide a standardized method for converting between various opiate medications in the emergency department (ED). By the end of this session, the learner will be able to: 1) define the term, "morphine milligram equivalents;" 2) describe the relative onset and duration of action of different pain medications often used in the emergency department; and 3) convert one opioid dose to another.Additionally, we aimed to evaluate the efficacy of the lecture and the infographic in increasing physicians' knowledge base of opioid medications and standardize the method of prescribing and converting between opioids in the ED. We designed and placed a simple, eye-catching infographic in the University of California, Irvine Emergency Department that depicted information pertaining to morphine equivalents and pharmacological properties of the opioids. We then presented a lecture on morphine equianalgesic doses, metabolism, and method for conversion between medications. In order to evaluate the functionality of the lecture and chart, we administered multiple surveys to ED providers pre- and post-lecture and placement of the chart in the ED. Our lecture and infographic included up-to-date literature and considered dose reductions, cross tolerance, and patient comorbidities. We designed the infographic to be visually appealing and simple for ease of use in a busy ED environment.
EDUCATIONAL METHODS
A lecture was designed to educate emergency department physicians and residents on the properties, metabolism and techniques for conversion between various opioid medications. Following the lecture, we walked through an example question with the participants. The lecture was presented at an Emergency Department conference.
RESEARCH METHODS
This lecture was presented at emergency medicine residency grand rounds. To evaluate the efficacy of our chart and educational lecture, we implemented a pre-presentation survey consisting of questions related to opiate conversions, metabolism, and medication characteristics without the help of the chart. After the presentation participants were once again asked to fill out the same set of questions on a post-presentation survey with the help of the chart. The effectiveness of the lecture and infographic was assessed by comparing participants' scores between the pre-presentation survey and post-presentation survey. A second post-presentation survey with the same set of questions was also sent out about 7 months after the presentation, to assess for retention of the information presented during the lecture. The responses were kept anonymous, though participants were asked for their level of training and four screening questions for the purpose of matching individual responses between the pre-presentation, initial post-presentation, and 7-month post-presentation surveys.
RESULTS
Seven initial post-presentation survey responses were matched to pre-presentation survey responses, while five 7-month post-presentation survey responses were matched to pre-presentation survey responses. Only one participant filled out all three surveys; this participant was found to have increased in score from pre-presentation survey (4/10) to immediate post-presentation survey (10/10), but decreased in score at the 7-month post-presentation survey (8/10). Five of the participants who filled out both the pre- presentation survey and immediate post-presentation survey showed improvement in their scores, one participant received the same score on both surveys, and one participant had a decrease in score. Between the five participants who filled out the pre-presentation survey and the 7-month post-presentation survey, one participant showed an increase in scores, two participants received the same score each time, and two participants decreased in scores.
DISCUSSION
Overall, the educational content and infographic allowed for improvement in a majority of the participants' scores between the pre-presentation survey and immediate post-presentation survey. However, it seems that retention of knowledge gained by the presentation waned as time passed, which manifested in most participants showing a decrease or no change in score between the pre-presentation survey and the 7-month post-presentation survey. In other words, through implementation of the infographic in the Emergency Department and educational lecture, we learned that the presentation and the walk-through of an example question contributed to immediate retention of knowledge of morphine equivalents. However, long-term retention of the knowledge about morphine equivalents was lacking. Given the small sample size of eleven participants, we are unable to definitively conclude whether this infographic and lecture are overall effective in improving knowledge, retention of knowledge, and change in clinical management. However, our results suggest that further larger studies could be conducted with the infographic and presentation as useful tools to advance EM physicians' knowledge and awareness of morphine milligram equivalents. Therefore, our hypothesis still stands that this infographic and lecture are useful tools that other EM programs could use and conduct studies to evaluate improvement in their learners' knowledge. The main takeaways are that educational lectures and visually-appealing graphics are able to enhance physicians' understanding of morphine equianalgesic doses in the immediate period after exposure, but must also be conducted with consistent follow-up to improve preservation of knowledge.
TOPICS
Morphine milligram equivalents, morphine equianalgesic doses, opioids, opiates, infographic.
PubMed: 37465775
DOI: 10.21980/J8RD29 -
PloS One 2022The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate...
INTRODUCTION
The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.
METHODS
We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.
RESULTS
In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).
CONCLUSION
Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.
Topics: Humans; Pain Management; Analgesics, Opioid; Cross-Sectional Studies; Practice Patterns, Physicians'; Ontario
PubMed: 36480526
DOI: 10.1371/journal.pone.0278508 -
JAMA Internal Medicine Sep 2019Prescription opioid misuse is a public health problem that leads to overdose. Although existing interventions focus on limiting prescribing to patients at high risk,...
IMPORTANCE
Prescription opioid misuse is a public health problem that leads to overdose. Although existing interventions focus on limiting prescribing to patients at high risk, individuals may still access prescription opioids dispensed to family members.
OBJECTIVE
To determine whether opioid prescriptions to family members were associated with overdose for individuals who themselves did not have an opioid prescription.
DESIGN, SETTING, AND PARTICIPANTS
We conducted a 1:4 matched case-control study using health care utilization data from 2004 through 2015 from a large US commercial insurance company. Eligible individuals were required to have at least 12 months of continuous enrollment and 1 or more family members in the database. Individuals who experienced overdose were identified by their first opioid overdose after the baseline period and matched to control participants by time in the database, calendar time, age, sex, and number of individuals in the family unit. Both groups were restricted to individuals with no prior opioid dispensing of their own. Data analysis was conducted from January 2018 to August 2018.
EXPOSURES
Any prior opioid dispensing to a family member, total morphine milligram equivalents dispensed to family members, and the type of opioid product dispensed.
MAIN OUTCOMES AND MEASURES
Individual odds of opioid overdose resulting in an emergency department visit or hospitalization were the primary end point. The primary analysis evaluated the odds of overdose among individuals whose family members had been dispensed an opioid. Sensitivity analyses examined the odds stratified by age and timing relative to the dispensing of opioids to family members.
RESULTS
A total of 2303 individuals who experienced opioid overdose and 9212 matched control individuals were identified. The mean (SD) age was 23.2 (18.1) years; 1158 affected individuals and 4632 control individuals (50.3%) were female. The mean (SD) time in the database before an overdose case was 3.2 (3.3) years. Prior opioid dispensing to family members was associated with individual overdose (odds ratio [OR], 2.89 [95% CI, 2.59-3.23]). There was a significant dose-response association between increasing amounts of opioids dispensed to family members and odds of overdose (>0-<50 morphine milligram equivalents per day: OR, 2.71 [95% CI, 2.42-3.03]; 50-<90 morphine milligram equivalents per day: OR, 7.80 [95% CI, 3.63-16.78]; ≥90 morphine milligram equivalents per day: OR, 15.08 [95% CI, 8.66-26.27]).
CONCLUSIONS AND RELEVANCE
In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions. Interventions may focus on expanding access to opioid antagonists, locking prescription opioids in the home, and providing greater patient education to limit fatal overdose among family members.
PubMed: 31233088
DOI: 10.1001/jamainternmed.2019.1064 -
American Journal of Preventive Medicine Oct 2021This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation...
INTRODUCTION
This study assesses the associations between the recent implementation of robust features of state Prescription Drug Monitoring Programs and the abrupt discontinuation of long-term opioid therapies.
METHODS
Data were from a national commercial insurance database and included privately insured adults aged 18-64 years and Medicare Advantage enrollees aged ≥65 years who initiated a long-term opioid therapy episode between Quarter 2 of 2011 and Quarter 2 of 2017. State Prescription Drug Monitoring Programs were characterized as nonrobust, robust, and strongly robust. Abrupt discontinuation was measured on the basis of high daily morphine milligram equivalents over the last 30 days of a long-term opioid therapy episode or no sign of tapering before discontinuation. Difference-in-differences models were estimated in 2019‒2020 to assess the association between robust Prescription Drug Monitoring Programs and abrupt discontinuation.
RESULTS
Among nonelderly privately insured adults, robust Prescription Drug Monitoring Programs were associated with an increase from 14.8% to 15.4% (4% relative increase, p=0.02) in the rate of ending long-term opioid therapy with ≥60 daily morphine milligram equivalents. For older Medicare Advantage enrollees, strongly robust Prescription Drug Monitoring Programs were associated with a reduction from 4.8% to 4.3% (10.4%, p=0.01) and from 3.0% to 2.4% (17.3%, p=0.001) in the rate of ending long-term opioid therapy with ≥90 and 120 daily morphine milligram equivalents, respectively. Prescription Drug Monitoring Programs robustness was not associated with clinically meaningful changes in the rate of discontinuing long-term opioid therapy without tapering.
CONCLUSIONS
Discontinuation without tapering was the norm for long-term opioid therapies in the samples throughout the study years. Findings do not support the notion that policies aimed at enhancing Prescription Drug Monitoring Program use were associated with substantial increases in abrupt long-term opioid therapy discontinuation.
Topics: Aged; Analgesics, Opioid; Humans; Medicare; Policy; Prescription Drug Monitoring Programs; United States
PubMed: 34233856
DOI: 10.1016/j.amepre.2021.04.019 -
Family Medicine Mar 2022Family physicians play a crucial role in addressing the opioid epidemic. We studied a novel peer-review opioid prescribing educational intervention for family medicine...
BACKGROUND AND OBJECTIVES
Family physicians play a crucial role in addressing the opioid epidemic. We studied a novel peer-review opioid prescribing educational intervention for family medicine residents that incorporates guided instruction from an interdisciplinary care team.
METHODS
We used a mixed-methods study design in the setting of a family medicine residency program in the Midwestern United States. Residents participated in small group, peer-to-peer discussions of patients chronically prescribed opioids with guidance and input from faculty, a pharmacist, and pharmacy students. Discussions followed a structured approach to evaluation based on guidelines, and written recommendations were given to the patients' resident primary care physician (PCP). For each patient, we reviewed electronic medical records to assess whether PCPs implemented the written recommendations. We used one-way analyses of variance to determine the statistical significance of changes made. The principal investigator interviewed seven participating residents to survey their satisfaction with the curriculum and collated suggestions for improvement.
RESULTS
Over a 3-year period, we reviewed 59 patients as part of the intervention; of these, 53 had complete records reviewed for this study. Patients' morphine milligram equivalent dosage (MME) declined modestly (P=.035). The number and proportion of recommendations implemented was correlated with the decline in MME (P=.004 and P=.013, respectively). Interviewed residents unanimously evaluated the curriculum positively, citing that the structured approach helped align their practices with guidelines.
CONCLUSIONS
The guided peer-review intervention effectively decreased chronic opioid use among patients, and residents positively evaluated the curriculum.
Topics: Analgesics, Opioid; Curriculum; Humans; Internship and Residency; Opioid-Related Disorders; Practice Patterns, Physicians'
PubMed: 35303305
DOI: 10.22454/FamMed.2022.864395