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Background: Combinations of alcohol use disorder (AUD) medications have been investigated, but few if any reports describe patients maintained on more than two options at the same time. Case presentation: We report a case of a middle-aged man hospitalized with gastrointestinal bleeding and acute kidney injury who had been maintained on four AUD medications (naltrexone, acamprosate, disulfiram, and gabapentin) and multiple psychiatric medications simultaneously as an outpatient. Direct quotations of his experiences with each AUD medication are included, revealing some deviations from what was prescribed as well as nuanced perceptions of effects. Overall, he tolerated the regimen well, but its AUD effects were insufficient to prevent several episodes of returning to alcohol use. He had very high hospital utilization. This prompted the initiation of an involuntary commitment, which began a period of at least six months of sobriety. Conclusions: Quadruple pharmacotherapy for AUD may be well tolerated and supportive of recovery for an extended period of time. However, for our patient the regimen ultimately failed to prevent multiple episodes of returning to alcohol use and serious medical complications. In refractory cases like this, more intensive interventions such as involuntary commitment can be considered. [ABSTRACT FROM AUTHOR]

Background: Knee osteoarthritis (KOA) is a high-priority problem among the aging population. While exercise has been shown to be beneficial in management of the disease, scalable and low-cost interventions to improve exercise in this population are lacking. Recent controversy over the value of corticosteroid injections for palliation has also arisen. Therefore, we designed a randomized, double-blind, placebo-controlled clinical trial with a 2-period crossover design to study (1) behavioral incentives to promote exercise and (2) corticosteroid injections to reduce pain and improve function in patients with KOA when compared to lidocaine only.Methods: The study design is a pragmatic factorial and crossover randomized clinical trial. Patients with KOA who are deemed eligible by their provider to receive knee injections and are able to walk without assistive devices will be recruited from clinical practices at four sites within the Veterans Affairs (VA) Health System in the USA. In total, 220 participants will be randomized to receive social incentives with gamification (i.e., incorporation of game elements) to promote exercise and compared to controls that receive a Fitbit but no incentive. Each patient will also be assigned to receive a blinded corticosteroid injection and a lidocaine-only injection in random order. The primary outcomes are the change in average daily step counts from baseline and the change in Knee Osteoarthritis Outcome Score (KOOS) from baseline. The study team will continuously collect step count, heart rate, and sleep data using activity monitors and patient-reported outcomes using the Way to Health (WTH) platform at two four-week intervals over eight months of follow-up. Mixed effects regression incorporating all available data points will be used for analysis.Discussion: The "Marching on for Veterans with Osteoarthritis of the Knee" (MOVE-OK) trial will take a pragmatic approach to evaluate (1) whether incentives based on behaviorally enhanced gamification can improve physical activity in this patient population and (2) whether corticosteroids injections reduce pain and disability in patients with KOA. Results of this trial will help to direct clinical practice and inform management guidelines.Trial Registration: ClinicalTrials.gov NCT05035810 . Registered on 5 September 2021. [ABSTRACT FROM AUTHOR]

Objective: The study objective was to determine the relationship of magnetic resonance imaging (MRI)‐detected features of patellofemoral joint osteoarthritis to pain and functional outcomes. Methods: We sampled 1,099 participants from the 60‐month visit of the Multicenter Osteoarthritis Study (mean ± SD age: 66.8 ± 7.5 years; body mass index: 29.6 ± 4.8; 65% female). We determined the prevalence of MRI‐detected features of patellofemoral joint osteoarthritis (eg, cartilage damage, bone marrow lesions, and osteophytes) and assessed the relationship between these features and knee pain severity, knee pain on stairs, chair stand time, and walking less than 6,000 steps per day. We evaluated the relationship of MRI features to each outcome using logistic and linear regression, adjusting for potential covariates. Results: Participants with cartilage damage in 3‐4 subregions had the highest mean pain severity (22.0/100; 95% confidence interval [CI]: 17.6‐26.4 mm). They also showed higher odds of having at least mild pain on stairs (odds ratio [OR]: 3.3; 95% CI: 1.7‐6.5) and of walking less than 6,000 steps per day (OR: 2.3; 95% CI: 1.1‐4.4) compared with those without cartilage damage. Participants with bone marrow lesions in 3‐4 subregions had higher odds of at least mild pain on stairs than those without (OR: 3.3; 95% CI: 2.2‐5.2). Participants with osteophytes in 3‐4 subregions also had higher odds of walking less than 6,000 steps/day (OR 2.1, 95% CI: 1.3‐3.5, respectively). Conclusion: MRI‐detected features of osteoarthritis of the patellofemoral joint are related to pain and functional performance. This knowledge highlights the need to develop treatments for those with patellofemoral joint osteoarthritis to improve pain and maximize function. [ABSTRACT FROM AUTHOR]

As pharmacists become established in their roles within Primary Care Network (PCN) multidisciplinary teams, it is important that their wellbeing and self‐care needs are supported. Here, the authors describe how the process of 'restorative clinical supervision', which they reframe as 'professional self‐care', brings pharmacists together to help them manage the complex professional and personal challenges they are now faced with. [ABSTRACT FROM AUTHOR]

Background. The increasing incidence of multidrug-resistant Gram negatives, such as carbapenem-resistant Enterobacteriaceae (CRE), has resulted in a critical need for new antimicrobials. Most studies of new antimicrobials have been performed in patients with nondrug-resistant pathogens. We performed a retrospective analysis of patients with CRE infections to inform the design of phase 3 clinical trials. Methods. This was a retrospective study at 22 centers in 4 countries. Baseline data, treatment, and outcomes were collected in patients with complicated urinary tract infection (cUTI)/acute pyelonephritis (AP), hospital-acquired bacterial pneumonia (HABP), ventilator-associated bacterial pneumonia (VABP), and bacteremia due to CRE. Results. Two hundred fifty-six cases of CRE infection were identified: 75 cUTI/AP, 21 HABP, 20 VABP, and 140 bacteremia. The patient population had significant comorbidities: 32.8% had chronic renal insufficiency, and 26.2% were immunocompromised. Illness severity at presentation was high: 29.3% presented with septic shock. Treatment regimens varied widely; however, a majority of patients received combination therapy. Outcomes were universally poor (28-day mortality was 28.1%) across all sites of infection, particularly in dialysis patients and those with sepsis. Conclusions. The CRE infections occured in patients with substantial comorbidities and were associated with high mortality and low rates of clinical cure with available antibiotics. Patients with these comorbidities are often excluded from enrollment in clinical trials for registration of new drugs. These results led to changes in the inclusion/exclusion criteria of a phase 3 trial to better represent the patient population with CRE infections and enable enrollment. Observational studies may become increasingly important to guide clinical trial design, inform on the existing standard of care, and provide an external control for subsequent trials. [ABSTRACT FROM AUTHOR]

Cardiovascular disease remains the leading cause of death worldwide compared with any other clinical condition, and improving medication adherence contributes to better outcomes. There is no single predictor of good or poor adherence. Patient beliefs about their illness can affect willingness to adhere to medicines. A health coaching approach can support medication adherence by raising the patient's awareness of their issue or problem and increasing their responsibility for managing their condition. This ultimately supports patients to be their own problem solvers. Cognitive behavioural therapy (CBT) can be used to support adherence where the patient works collaboratively with a therapist to identify and re-evaluate the content and effects of their thoughts, beliefs and emotional states that affect adherence. Both health coaching and cognitive behavioural change techniques have been used successfully in routine medicinesrelated consultations including use of the Four Es (explore, educate, empower, enable) framework to support adherence. Use of cognitive behavioural change techniques, including health coaching and CBT, can support patients to better engage with their medicines-related activity to improve health outcomes. [ABSTRACT FROM AUTHOR]

This article draws lessons from ACDI/VOCA, CARE, and World Vision-implemented food security programmes to answer three questions: how can push/pull activities better integrate the extremely poor into 1) output and 2) input markets? And 3) how can push/ pull programme activities help improve intra-household gender dynamics and financial decision-making to improve the food and nutrition security of household members? In output markets the lessons include: 1) that market development and savings group interventions can be implemented by the same officer; and 2) projects should move early to have a private sector provider take over the village savings and loan associations. While there are constraints in the input markets, there are also push strategies for increasing production, including direct delivery of inputs to farmers, vouchers to increase demand, and Farmer Business Group development to increase collective input buying and pull strategies such as linkages with buyers for the selling of products and tapering down subsidies. Intrahousehold gender equitable decision-making can positively impact the food security of the household members. Mixed gender Village Economic and Social Associations are efficient in tackling intra-household decision-making. This allows the provision of flexible and efficient financial services as well as an opportunity to engage husbands and wives in gender-related dialogues. [ABSTRACT FROM AUTHOR]

Just like urban residents, rural citizens want educational, cultural, and technological resources delivered in an affordable manner appropriate to their locale. Rural communities and elected officials strive to leverage their limited resources to meet critical needs, provide services, and improve their quality of life. The Rural Library Project, a small nonprofit in Georgia, is working with rural communities to organize and engage talent, gather resources, and value the public library as a center for lifelong learning and community development. [ABSTRACT FROM PUBLISHER]

Recently, a new class of biocompatible elastic polymers loaded with small ferrous particles (magnetoelastomer) was developed at Lawrence Livermore National Laboratory, Livermore, CA. This new material was formed as a thin film using spin casting. The deformation of this material using a magnetic field has many possible applications to microfluidics. Two methods will be used to calculate the deformation of a circular magnetoelastomeric film subjected to a magnetic field. The first method is an arbitrary Lagrangian-Eulerian (ALE) finite-element method (FEM) and the second is based on nonlinear continuum electromagnetism and continuum elasticity in the membrane limit. The comparison of these two methods is used to test/validate the FEM. [ABSTRACT FROM AUTHOR]

The composition and biodegradability of streamwater dissolved organic matter (DOM) varies with source material and degree of transformation. We combined PARAFAC modeling of fluorescence excitation–emission spectroscopy and biodegradable dissolved organic carbon (BDOC) incubations to investigate seasonal changes in the lability of DOM along a soil-stream continuum in three soil types: bog, forested wetland and upland forest. The percent BDOC ranged from 7 to 38% across all sites, and was significantly greater in soil compared to streamwater in the bog and forested wetland, but not in the upland forest. The percent BDOC also varied significantly over the entire sampling period in soil and streamwater for the bog and forested wetland, as BDOC peaked during the spring runoff and was lowest during the summer months. Moreover, the chemical quality of DOM in wetland soil and streamwater was similar during the spring runoff and fall wet season, as demonstrated by the similar contribution of protein-like fluorescence (sum of tyrosine and tryptophan fluorescence) in soil water and in streams. These findings suggest that the tight coupling between terrestrial and aquatic ecosystems is responsible for the delivery of labile DOM from wetland soils to streams. The contribution of protein-like fluorescence was significantly correlated with BDOC ( p < 0.001) over the entire sampling period indicating DOM is an important source of C and N for heterotrophic microbes. Taken together, our findings suggest that the production of protein-rich, labile DOM and subsequent loss in stream runoff might be an important loss of labile C and N from coastal temperate watersheds. [ABSTRACT FROM AUTHOR]

People in the Arctic face uncertainty in their daily lives as they contend with environmental changes at a range of scales from local to global. Freshwater is a critical resource to people, and although water resource indicators have been developed that operate from regional to global scales and for midlatitude to equatorial environments, no appropriate index exists for assessing the vulnerability of Arctic communities to changing water resources at the local scale. The Arctic Water Resource Vulnerability Index (AWRVI) is proposed as a tool that Arctic communities can use to assess their relative vulnerability–resilience to changes in their water resources from a variety of biophysical and socioeconomic processes. The AWRVI is based on a social–ecological systems perspective that includes physical and social indicators of change and is demonstrated in three case study communities/watersheds in Alaska. These results highlight the value of communities engaging in the process of using the AWRVI and the diagnostic capability of examining the suite of constituent physical and social scores rather than the total AWRVI score alone. [ABSTRACT FROM AUTHOR]

The article presents a commentary about the recent ocean energy in the U. S. It provides information on the current state of technology specifically needed in the research for energy sourced from the oceans which also be a viable source of water and hydrogen fuel. Factors driving and affecting the implementation of ocean energy technology in the U. S. are discussed more.

In many areas of Northern and Western Alaska, small streams and shallow lakes serve as community raw water supplies. These water supplies freeze completely during winter. In order to supply drinking water during the 6–9 month winter, communities store water that was treated during summer. A chlorine residual is maintained in the stored water. Raw water sources derived from surface water may be heavily laden with dissolved organic matter. At utilities where organic matter escapes treatment, the potential for accumulation of disinfection by-products (DBPs) during storage is a significant health concern. The following study was performed to evaluate this potential threat. Water was collected from five operating utilities, four that normally store water for 6–9 months and one that produces drinking water year-round. Raw, filtered (i.e., unchlorinated) and “finished” (i.e., filtered and chlorinated) water samples were collected during the summer pumping season and stored in the laboratory for 8 months. In order to mimic practice in the field, the chlorine residual was maintained in the finished water for the full storage period. While the concentration of DBPs in the finished water varied over the study period, there was not a statistically significant trend from the third to the eighth month of storage. The observed DBP values were strongly a function of the type of treatment system used. Those systems passing more organic matter had higher DBP values throughout the storage period. The ultraviolet absorbance at 254 nanometers (UV254) decreased continuously in the finished water coincident with chlorine consumption. UV254, often used as a surrogate for DBPs, remained constant during the entire storage periodin raw and filtered water samples. Filtered water that was stored prior to chlorination accumulated fewer DBPs than finished water that was continuously chlorinated during the storage period. This result suggests that storing filtered water instead of finished water for long periods would limit DBP exposure to consumers. This conclusion was based on a comparison of DBP formation potentials (i.e., raw and filtered water) to DBPs (i.e., finished water). It is important to note that DBP formation potentials are based on a 24 hchlorine contact time. If long term storage were provided for filtered water, a smaller volume of secondary storage would still be needed to provide contact time for disinfection. [ABSTRACT FROM AUTHOR]