Greenleaf University

FigureFigureResidency is a time of excitement, optimism, future-building ideas, and bonding, the time we envision change and potential possibilities. My residency class was composed of eight amazing individuals, two women and six men. We had people from all stages of life: single and married, some on their second career, some practically fresh out of the womb. Some were closer friends than others, but we all went through the toils of residency together in the pit of the ED, lectures, and occasional retreats. We all eventually graduated and became emergency physicians, bonded by that identity, attending conferences, receiving Emergency Medicine News, and realizing that our experiences were fairly similar, even though we may not have been able to share those experiences with other doctors. Now, almost 13 years later, only four of those eight individuals still work in EDs. Only 50 percent have continued in the career they spent four years (or 12 years, depending on your perspective) of their lives, time, and energy doing for very little pay. The problem here is that this is not surprising to anyone in the ED. We expect that many, if not most, EPs will retire within 10 to 20 years after being in the trenches, but this retirement is not like that of the Silicon Valley billionaires. We don't retire and go golfing. We retire from the ED, not from work. Many continue to remain in the medical field, simply because they enjoy the work of medicine and carry the title physician. I haven't seen any articles about retirement that referenced a community for retirees. Many talk about exit plans and strategies. Many before me left with a bon voyage kind of party. Many continued to socialize with those they knew from their working days. But no organizational attempt has been made to keep these physicians involved in our dysfunctional yet cohesive family. The COVID years have taught me that community, socialization, and feeling a part of something, as opposed to apart from something, plays a huge role in our happiness. A Wake-Up Call The American College of Emergency Physicians, the American Academy of Emergency Medicine, and the American Board of Emergency Medicine now offer retirement status. (https://bit.ly/3sIA13r; https://bit.ly/350U05G; https://bit.ly/35hNTtw.) The photo accompanying ACEP's retirement webpage shows older EPs, but a better reflection of reality would be of physicians in their 40s and 50s who are pivoting and piecing together their own path. We need a space where creating your own medical business could be a discussion based on that with which we are actually familiar: the ED. We need to learn how to bring the lessons learned from the ED to our new businesses, a space where we can help one another while reconnecting with friends. We need a place where we can talk money without being held to other specialty standards, where we can create and carve out specialties (that EPs are actually doing when they retire or pivot away from the ED) while earning a higher income and having a better lifestyle. As my EM career has begun its descent into night and my Cannabis medicine career rises up out of the shadows, I wonder, how do we do it? How do we as a collective 50 percent in our 40s and 50s create a communal, collaborative organization fueled by our pivots in medicine, to support others who inevitably end up in the same place, either due to preference or out of exhaustion? I'd love to hear your suggestions.

Figure: The rate of drug overdose deaths involving methadone increased from 0.3 in 1999 to 1.8 in 2006, then declined to 1.0 in 2016. The rate in 2017 was the same as in 2016. Source: Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018; https://bit.ly/2TtCkq6.FigureWe are in the midst of an opioid crisis in which the only options for treatment are opioid-based. Let me take this a step further: Opioids are mu, kappa, and delta receptor agonists, and some treatment strategies are focused on opioid antagonists (or blockers). Some treatment strategies are actually partial agonists (buprenorphine [Subutex]) or full agonists (methadone). There are currently no strategies that employ any other receptors outside of the mu, kappa, and delta opioid receptors. That's the first issue. Once patients have transitioned to another opioid receptor agonist or antagonist and are thought to have been successfully treated, they are still at risk for opioid overdose and death. (See graph.) Is this truly a “successful” treatment? This is the second issue. Those who are able to maintain methadone rehabilitation are required to go to a methadone clinic weekly or monthly for continued “treatment.” Eventually, they can have problems with withdrawal from methadone or, worse, fall back into illegal opioid use. (Issue 3.) We have set the bar for treatment success for opioids so low that we think getting patients on buprenorphine, methadone, and the rest is a success. It is not, as demonstrated by the graph. What would an ideal treatment strategy for opioid dependence and addiction be? A medication that does not affect the opioid receptors mu, kappa, and lambda. A medication that independently does not have a risk for overdose and death. A medication that does not lead to opioid withdrawal or catapult patients back into opioid abuse in the long term. A medication from which patients can be easily weaned off and that does not create further dependence and abuse. Am I dreaming? Does a medication that fulfill all of these requirements exist? Yes, but it is not an isolated medication and requires titration to therapeutic levels. A combination of cannabinoids—CBD and THC—used together can allow us to treat patients with opioid dependence. CBD and THC combinations fulfill all the prerequisites set forth in the issues I outlined. Cannabinoids affect the CB1 and CB2 receptors. There have been no direct lethal overdoses from THC or CBD. Cannabis does not cause an opioid-like withdrawal. While there is documentation of Cannabis withdrawal, it is more akin to caffeine withdrawal. It does not require hospitalization or inpatient treatment. Patients can be easily weaned off Cannabis. The data for further dependence and abuse are unknown. One of my current patients is a 39-year-old man with a history of chronic pancreatitis since age 27 who was started on sublingual fentanyl and had been slowly increased to 400 mcg sublingual fentanyl hourly (#24 fentanyl per day). This is 1248 mg morphine equivalents per day, which puts a patient at an 8.9 times higher risk of overdose, according to MDCalc. The patient presented with a request to stop using all fentanyl. He had never been a drug addict, nor had he taken anything that was not prescribed. In fact, he was also receiving clonidine patches and abdominal blocks routinely for pain management. With the use of all oral and sublingual CBD and THC products, he was able to remove 83 percent of his fentanyl sublingual use within 14 days. The patient did experience some anxiety and pain due to withdrawals, but was able to tolerate it at home without any dehydration, inpatient treatment, or use of other opioids. He is currently in the process of removing the last portion of the fentanyl (currently day 14 of removal, sleeping seven to eight hours, and dealing with some anxiety), with the worst part of this removal being insomnia. The patient in general does not like nor respond well to THC, thus requiring large doses of CBD instead to assist with opioid removal. In between the fentanyl removal, he was able to stop all Cannabis products (about one month between removal periods). The patient was motivated to stop all Cannabis products at completion. Treatment for this patient has been successful so far with all the issues I noted earlier. Updates and other cases will be presented in next month's column, lest anyone think this is the only patient (or a unicorn) who has had such successful results. Medications are only as useful as the advisor. If we physicians are armed with knowledge about the uses, advantages, dangers, and pitfalls of a medication, we can use them to bring patients to better health.

Abstract The upheaval of providers and their patients has led to many changes in the way people live and work. In addition to the changes in Personal Protective Equipment (PPE) guidelines, there has been evidence of rapid adoption of telehealth services. In April of 2020, the American Dental Association’s Health Policy Institute released a report stating that 1 in 4 dentists nationally were utilizing teledentistry to perform limited evaluations. Many of these dentists are new to teledentistry, and unfortunately, direct‐to‐patient consultations yield limited clinical outcomes. The more traditional methods of using teledentistry have been extending the reach of dental care for over a decade, using an allied team member such as a dental hygienist or expanded‐function dental assistant. As dentistry adapts to this new environment, it is important that there be adequate awareness of the diverse uses of teledentistry to meet the needs of the population. This brief, outlines one dental clinic’s attempt at providing a broad use of teledentistry.

The objectives of the present study were to characterize farrowing space (FS) utilization efficiency on commercial farms and to examine the relationships between FS utilization efficiency measurements and those possible factors. A questionnaire survey was undertaken to obtain information on FS utilization from 115 breeding farms. The FS data of the 94 farms (81.7%) that returned the questionnaires were coordinated with the respective reproductive performance data. The 94 farms were categorized into two groups on the basis of the upper 25th percentile of number of pigs weaned per FS per year: high-performing farms and ordinary farms based on the FS utilization efficiency. In addition to herd reproductive performance data, a set of time-series data in 13 four-week periods during a year was created for each farm to obtain mean and its coefficient of variation (CV, %) as a measurement of within-farm variability for number of females served per 4-week. Correlation analysis and regression analysis were applied to the data. Means (±SEM) of pigs weaned per FS per year, litters farrowed per FS per year and the CV of the total number of females served per 4-week in a year were 97.33±2.70 pigs, 9.86±1.28 litters and 12.82±0.79%, respectively. High-performing farms had 42.91 more pigs weaned per FS per year, 3.89 more litters farrowed per FS per year and 4.83% lower CV for the number of females served than ordinary farms (P<0.05). In modelling, a higher number of pigs weaned per FS per year was associated with annual farrowing rate and a lower CV% for the number of females served 16 weeks previously (P<0.01). In conclusion, a higher FS utilization efficiency appeared to be related to mating management on female pigs.

The laboratory evaluation for a recurrent stone former can be divided into serum tests, urine analysis/microscopy, stone analysis, and 24-h urine collection. Serum tests for all stone formers should include a basic metabolic panel in addition to serum phosphorus and uric acid and when applicable an intact parathyroid hormone level. Serum testing is also important to assess for adverse effects in the follow-up of patients on pharmacological therapy to help prevent urolithiasis. In the urinalysis, the urine pH, specific gravity along with microscopic analysis can further aid in the differential diagnosis for the etiology of urolithiasis. Extracted or passed stones should be sent for chemical analysis and examination of urine sediment for crystals may further aid in determining the type of stone formed if an intact stone is not available. Repeat stone analysis should be obtained in patients who do not respond to medical therapy and continue to have stone recurrence. The 24-h urine collection can further guide dietary and medical therapy to decrease the risks of recurrence and can also be used to judge the efficacy of treatment as well as provide patients with feedback regarding their treatment.

Native grasslands of south-eastern Australia have been reduced to one per cent of their historical range. Severe fragmentation of this once widespread flora poses a serious threat to the viability of many species that exist as small and isolated populations (Morgan 1998). 'Rutidosis leptorrhynchoides' (Button Wrinklewort), a multi-stemmed, herbaceous perennial is an Asteraceae species endemic within these broader temperate southeastern grassland communities. The species is listed as threatened under Victoria's 'Flora and Fauna Guarantee Act 1998' and as endangered under the Commonwealth's 'Environment Protection and Biodiversity Conservation Act 1999'. Only 20 natural populations of 'Rutidosis are thought to remain within two broad zones of south-eastern Australia - one across New South Wales and the Australia Capital Territory and the other across southern and southwestern Victoria (Young et al. 1999).

Held at the Crown Plaza Hotel. "The world's largest X-

This paper discusses the early use of a prototype multi-user virtual environment (MUVE) designed to enhance traditional, office-based adolescent psychotherapy.

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