Community Opioid Dispensing after Injury (CODI): Cohort characteristics and opioid dispensing patterns

BACKGROUND

Despite a focus of opioid-related research internationally, there is limited understanding of long-term opioid use in adults following injury. We analysed data from the 'Community Opioid Dispensing after Injury' data linkage study.

AIMS

This paper aims to describe the baseline characteristics of the injured cohort and report opioid dispensing patterns following injury-related hospitalisations.

METHODS

Retrospective cohort study of adults hospitalised after injury (ICD-10AM: S00-S99, T00-T75) in Queensland, Australia between 1 January 2014 and 31 December 2015, prior to implementation of opioid stewardship programs. Data were person-linked between hospitalisation, community opioid dispensing and mortality collections. Data were extracted for 90-days prior to the index hospital admission, to establish opiate naivety, to 720 days after discharge. Median daily oral morphine equivalents (i.e., dose) were averaged for each 30-day interval. Cumulative duration of dispensing and dose were compared by demographic and clinical characteristics, stratified by drug dependency status.

RESULTS

Of the 129,684 injured adults, 61.3 % had no opioids dispensed in the 2-year follow-up period. Adults having any opioids dispensed in the community (38.7 %) were more likely older, female, to have fracture injuries and injuries with a higher severity, compared to those with no opioids dispensed. Longer durations and higher doses of opioids were seen for those with pre-injury opioid use, more hospital readmissions and repeat surgeries, as well as those who died in the 2-year follow-up period. Median dispensing duration was 24-days with a median daily end dose of 13 oral morphine equivalents. If dispensing occurred prior to the injury, duration increased 10-fold and oral morphine equivalents doubled. Adults with a documented dependency prior to, or after, the injury had significantly longer durations of use and higher doses than the rest of the cohort receiving opioids. Approximately 7 % of the total cohort continued to be dispensed opioids at 2-years post injury.

CONCLUSION

This is a novel population-level profile of opioid dispensing patterns following injury-related hospitalisation, described for the time period prior to the implementation of opioid stewardship programs and regulatory changes in Queensland. Detailed understanding of this pre-implementation period is critical for evaluating the impact of these changes moving forward.

Electric personal MObility DEvices Surveillance (E-MODES) study: Injury presentations to emergency departments in Brisbane, Queensland

OBJECTIVE

The rapid increase in e-mobility globally, including in Australia, has seen a concurrent increase in e-mobility-related injuries. Monitoring and understanding the patterns of injuries is essential to preserving community safety and making responsive and effective policy decisions regarding their safe use.

METHODS

This study reports on the first phase of the E-MODES study, a proactive injury surveillance initiative to examine the incidence and nature of injuries, their circumstances, contributing factors, and treatment, presenting to three hospital emergency departments (EDs) in Brisbane, the first Australian city to trial shared e-scooters.

RESULTS

During the 31-month study period, there were 1048 ED presentations related to e-mobility, the vast majority (90.8%) involving e-scooters, with males accounting for 64.3% of cases, the most common age group being 25-34 years, and weekends being the most common period of the week for presentations. The most common injury was fractures (37%), and the upper extremities and head/face were the most commonly injured body regions.

CONCLUSION

Contributing risk factors of alcohol use, not wearing a helmet, and speeding, were prevalent, though poorly recorded and only alcohol use proportions varied by age and gender, with males being more likely than females to have alcohol use reported. Recommendations to support e-mobility-related injury surveillance and safety outcomes include improved data standardisation and sharing.

Hospital outpatients' responses to taking medications with driving warnings

OBJECTIVE

The study investigates the knowledge, intentions, and driving behavior of persons prescribed medications that display a warning about driving. It also examines their confidence that they can self-assess possible impairment, as is required by the Australian labeling system.

METHOD

We surveyed 358 outpatients in an Australian public hospital pharmacy, representing a well-advised group taking a range of medications including those displaying a warning label about driving. A brief telephone follow-up survey was conducted with a subgroup of the participants.

RESULTS

The sample had a median age of 53.2 years and was 53 percent male. Nearly three quarters (73.2%) had taken a potentially impairing class of medication and more than half (56.1%) had taken more than one such medication in the past 12 months. Knowledge of the potentially impairing effects of medication was relatively high for most items; however, participants underestimated the possibility of increased impairment from exceeding the prescribed dose and at commencing treatment. Participants' responses to the safety implications of taking drugs with the highest level of warning varied. Around two thirds (62.8%) indicated that they would consult a health practitioner for advice and around half would modify their driving in some way. However, one fifth (20.9%) would drive when the traffic was thought to be less heavy and over a third (37.7%) would modify their medication regime so that they could drive. The findings from the follow-up survey of a subsample taking target drugs at the time of the first interview were also of concern. Only just over half (51%) recalled seeing the warning label on their medications and, of this group, three quarters (78%) reported following the warning label advice. These findings indicated that there remains a large proportion of people who either did not notice or did not consider the warning when deciding whether to drive. There was a very high level of confidence in this group that they could determine whether they were personally affected by the medication, which may be a problem from a safety perspective.

CONCLUSION

This study involved persons who should have had a very high level of knowledge and awareness of medication warning labeling. Even in this group there was a lack of informed response to potential impairment. A review of the Australian warning system and wider dissemination of information on medication treatment effects would be useful. Clarifying the importance of potential risk in the general community context is recommended for consideration and further research.

Consumer perceptions of medication warnings about driving: a comparison of French and Australian labels

OBJECTIVE

Little research has examined user perceptions of medication warnings about driving. Consumer perceptions of the Australian national approach to medication warnings about driving are examined. The Australian approach to warning presentation is compared with an alternative approach used in France. Visual characteristics of the warnings and overall warning readability are investigated. Risk perceptions and behavioral intentions associated with the warnings are also examined.

METHOD

Surveys were conducted with 358 public hospital outpatients in Queensland, Australia. Extending this investigation is a supplementary comparison study of French hospital outpatients (n = 75).

RESULTS

The results suggest that the Australian warning approach of using a combination of visual characteristics is important for consumers but that the use of a pictogram could enhance effects. Significantly higher levels of risk perception were found among the sample for the French highest severity label compared to the analogous mandatory Australian warning, with a similar trend evident in the French study results. The results also indicated that the French label was associated with more cautious behavioral intentions.

CONCLUSION

The results are potentially important for the Australian approach to medication warnings about driving impairment. The research contributes practical findings that can be used to enhance the effectiveness of warnings and develop countermeasures in this area. Hospital pharmacy patients should include persons with the highest level of likelihood of knowledge and awareness of medication warning labeling. Even in this context it appears that a review of the Australian warning system would be useful particularly in the context of increasing evidence relating to associated driving risks. Reviewing text size and readability of messages including the addition of pictograms, as well as clarifying the importance of potential risk in a general community context, is recommended for consideration and further research.

Genotyping of Toll-like receptor 4, myeloid differentiation factor 2 and CD-14 in the horse: An investigation into the influence of genetic polymorphisms on the LPS induced TNF-α response in equine whole blood

The inter- and intra-species differences in the response to lipopolysaccharides (LPS) are well recognised in mammalian species. It has been hypothesized that these differences can be attributed to genetic polymorphisms in the components involved in LPS signal transduction. These components include the cluster of differentiation factor 14 (CD-14), a membrane bound protein on the surface of mononuclear cells that recognises LPS and a receptor complex consisting of Toll-like receptor-4 (TLR-4) and myeloid differentiation factor-2 (MD-2). Sequencing of these three proteins in humans and mice revealed that all three are susceptible to polymorphic alterations, influencing the response to LPS. Previous experiments in the horse showed large inter-individual variations in the response to LPS. With the aim to assess this inter-individual variation, we performed a whole blood assay in 10 healthy horses as a functional assay to study the responsiveness to LPS. In 3 out of the 10 horses, LPS-induced TNF-alpha production was significantly lower compared to the overall mean. Subsequently the entire cDNA sequence encoding for the TLR-4, MD-2 and CD-14 protein was documented for each horse. Although mutations were observed in the sequence of TLR-4, these could not be related to an altered response to LPS in the concentration used in this study, as determined in the whole blood assay. Despite the various mutations found in the TLR-4 receptor protein, no alterations could be found in either the MD-2 or CD-14 gene, which are obviously more conserved structures.

General practitioner perceptions of surgical waiting times

This study explored general practitioners' (GP) perceptions of waiting times and the importance of these perceptions in choosing a surgeon. A randomly selected sample of GPs in the Hunter Area of New South Wales, Australia, provided information prospectively on patients referred to a surgeon. The results indicated that GPs feel a lack of private health insurance makes only a small difference in waiting time to see a surgeon but a large difference in the waiting time for an operation. Additionally, GPs consider that sizeable numbers of patients will wait longer than they consider reasonable for surgical consultations and procedures. However, perceptions of waiting times do not appear to have a major influence on the choice of surgeon.

Reinstating the person in the professional: reflections on empathy and aesthetic experience

Although the literature seems to suggest that the caring professions have embraced a view of the 'whole' person, there are some important weaknesses in current models and practices. Nurses, as people, are often left out of the care equation. To offer creative and rounded care, nurses need to accept all aspects of both their own personalities and those of their clients. This exploratory paper argues that aesthetics and the arts are influential forces in all our lives, however, despite this, they are rarely discussed explicitly in the nursing literature. The value of aesthetics and the arts to the nursing profession is introduced and explored through reflections on the concept of empathy.

Marginality and the role of the clinical teacher

This paper discusses the concept of marginality and its relevance to an understanding of the role of the clinical teacher. Despite having a rather chequered history, the notion of marginality has proved, nonetheless, to be a powerful and resilient stimulus for many writers from a variety of backgrounds. After a brief overview of the historical development of the concept, this paper focuses on the theoretical framework proposed by Dickie-Clark which is found to have value as both an accessible and flexible means of analysing a wide range of social and individual phenomena. It is this framework that is used to examine the position of the clinical teacher. The essence of the argument is that the clinical teacher is at a pivotal level at the intersection of two relatively distinct hierarchies (the formal educational and the informal clinical) which need to be reconciled if the clinical teacher is to be effective. Brief references are made also to Third World studies as an illustration of how seemingly remote concepts can be employed creatively to highlight some hitherto unconsidered aspects of the clinical teacher's role.

Chromium (III) thiamin diphosphate: a new probe of enzyme coenzyme--metal ion binding. Interaction with wheat germ pyruvate decarboxylase

Chromium (III) thiamin diphosphate (CrTDP) is a substitutionally inert complex which is a physical and kinetic probe of the binding mode of metal ion and coenzyme in thiamin diphosphate (TDP) dependent enzymes. CrTDP is prepared by reaction of aquated Cr (III) and TDP and purifed by ion-exchange chromatography. CrTDP binds to the apoenzyme of wheat germ pyruvate decarboxylase, giving an inactive holoenzyme. Chromium (III) ion binds to the apoenzyme in a manner that suggests, in light of the results with CrTDP, that there are two metal ion binding sites. Extension of the use of CrTDP to other enzymes can give specific information about binding and can introduce an active site reporter group

Mechanical and electrical responses of single innervated crab-muscle fibres

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Giant Muscle Fibers in a Barnacle, Balanus nubilus Darwin

Cross-striated muscle fibers of very large size have been found in the scutal-tergal adductor and depressor muscles of the large barnacle B. nubilus. Adductor muscle fibers are up to 2 mm thick. They are innervated by separate nerves, each supplying one end, but not the central region, with terminals; each fiber receives two or three excitor axons. Depressor muscle fibers are up to 1.4 mm thick and receive multiterminal innervation along their entire length; they are innervated by two excitor axons. Postsynaptic potentials are of small or large size and lead to small or large twitches; they do not show facilitation. The muscle fibers shorten to as little as one-sixth resting length.