Fringe jump compensation techniques for the time-averaging zero-crossing phase measurement in the KSTAR millimeter-wave interferometer

A fringe jump compensation algorithm has been developed for a phase measurement that measures the phase within a single fringe. The algorithm is extremely useful in the case of the time-averaging zero-crossing phase detector on noisy environments. When the noise level on the measurements is not sufficiently suppressed, the signals near the fringe jump show a negative slope instead of a sharp drop. The slope brings an ambiguity over the compensation process. An algorithm with an additional channel that measures the phase of a half fringe shift has been applied in the millimeter-wave interferometer on the Korea Superconducting Tokamak Advanced Research device. These techniques removed the ambiguity in most cases. The algorithm can provide a most simple, robust, and cost-effective solution for the phase measurement system in various fields.

Safety of Risperidone for Acute Agitation and Alcohol Intoxication in Emergency Department Patients

BACKGROUND

Acute agitation in the setting of alcohol intoxication is commonly encountered in the Emergency Department (ED). In this setting, expert consensus guidelines recommend haloperidol over second-generation antipsychotics due to their limited safety data in alcohol intoxication.

OBJECTIVE

The primary objective was to compare vital sign changes prior to and after risperidone administration between ED patients presenting with alcohol intoxication [ETOH (+)] and without alcohol intoxication [ETOH (-)]. The secondary objective was to assess the effect of benzodiazepine co-administration with risperidone on vital signs.

METHODS

This was a retrospective chart review of patients who received oral risperidone for acute agitation at two university EDs between January 1, 2012 and December 31, 2015. Vital signs (oxygen saturation, systolic and diastolic blood pressure, heart rate, and respiratory rate) were compared in patients who had ingested alcohol with those who had not.

RESULTS

There were 785 patients without evidence of alcohol intoxication who received risperidone in the ED, and 52 patients with alcohol intoxication who received risperidone. Overall, risperidone with and without alcohol intoxication and benzodiazepine administration had no statistically significant effect on vital signs (p = ns for all comparisons).

CONCLUSION

This study suggests that oral risperidone may be a safe option for acute agitation in patients presenting to the ED with alcohol intoxication.

Update on the UC San Diego Healer Education Assessment and Referral (HEAR) Program

Burnout, depression and suicide are rampant amongst health care professionals. Current evidence shows the problem is worsening. In the aftermath of physician suicides, the Physician Wellbeing Committee created the UC San Diego Healer Education Assessment and Referral (HEAR) Program in 2009 in collaboration with the American Foundation for Suicide Prevention (AFSP). This article chronicles the HEAR program from inception through June 2017. Initially created to address medical students, residents and faculty physician duress, HEAR has now expanded to embrace pharmacists, nurses and clinical staff within UC San Diego Health. HEAR operates through two mechanisms: 1) a program of ongoing education and outreach, and 2) encouragement of all personnel to annually engage in the online, anonymous, interactive screening program, created by the AFSP (known as SDSQ at UC San Diego Health). Since inception in May 2009 through June 2017, 1,537 UC San Diego health care personnel have been screened, 320 individuals have dialogued with a counselor either in person, by phone or electronically, and more than 300 have been referred confidentially for evaluation and treatment by a mental health professional, usually a community psychiatrist. While tracking death by suicide remains challenging, we have reason to believe that the prevalence of suicide has diminished during this time. The UC San Diego HEAR Program is one cost-effective model for addressing this current crisis in U.S. health care. This AFSP model has been adopted by many other schools of medicine and is now ready for use with clinicians of all disciplines.And whoever saves a life, it is considered as if he saved an entire world.— Mishnah Sanhedrin 4:5; Babylonian Talmud Tractate Sanhedrin 37a

The first pilot study of expanded newborn screening for inborn errors of metabolism and survey of related knowledge and opinions of health care professionals in Hong Kong

INTRODUCTION

Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM.

METHODS

The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling.

RESULTS

In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years.

CONCLUSION

The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Population scale retrospective analysis reveals distinctive antidepressant and anxiolytic effects of diclofenac, ketoprofen and naproxen in patients with pain

Currently approved monoamine modulating antidepressant and anxiolytic pharmaceutics fail in over one third of patients due to delayed and variable therapeutic effect, adverse reactions preceding the therapeutic action, and adherence issues. Even with adequate adherence to the regimen and tolerability, one third of the patients do not respond to any class of antidepressants. There is a strong correlation between treatment resistant depression and increase in inflammatory cytokines in plasma and cerebrospinal fluid. Furthermore, epidemiological studies suggest that depression and anxiety are commonly comorbid with pain and inflammation. While a link between pain, inflammation and depression has been suggested it remains unclear which anti-inflammatory treatment may be beneficial to patients with depression and anxiety due to pain. Here, we analyzed 430,783 FDA adverse effect reports of patients treated for pain to identify potential antidepressant and anxiolytic effects of various anti-inflammatory medications. Patients treated for depression or patients taking any known antidepressants were excluded. The odds ratio analysis of 139,072 NSAID reports revealed that ketoprofen was associated with decreased reports of depression by a factor of 2.32 (OR 0.43 and 95% Confidence Interval [0.31, 0.59]) and decreased reports of anxiety by a factor of 2.86 (OR 0.35 [0.22, 0.56]), diclofenac with decreased depression reports by a factor of 2.22 (OR 0.45 [0.40, 0.49]) and anxiety by a factor of 2.13 (OR 0.47 [0.41, 0.54]), while naproxen decreased depression reports by a factor of 1.92 (OR 0.52 [0.49, 0.57]) and anxiety by a factor of 1.23 (OR 0.81 [0.75, 0.88]). Other NSAIDs did not exhibit any noticeable antidepressant and/or anxiolytic effect.

Ayahuasca: An ancient sacrament for treatment of contemporary psychiatric illness?

Ayahuasca is a traditional psychoactive sacrament that's been used in Amazonian shamanic rituals for hundreds of years. Ayahuasca is notorious for its psychedelic properties produced from the combination of monoamine oxidase inhibitors (MAOIs) found in the Banisteriopsis caapi vine and N-N-dimethyltryptamine from Psychotria viridis or Diplopterys cabrerana. Recently, ritual use of ayahuasca has increased and garnered attention for its potential in treating mental illnesses, such as substance use and depressive disorders. Due to its MAOI properties, there are serious drug interactions that may be of concern among patients who participate in ayahuasca use. The objectives of this paper are to describe ayahuasca's pharmacology, potential drug interactions, and clinical data for its treatment potential in psychiatric illness.

Pharmacist training in suicide prevention

OBJECTIVE

Suicide in the United States is a major preventable public health problem. Pharmacists need to be educated on suicide prevention strategies so that they can increase their own awareness and identify patients at-risk. A training program for pharmacists was used to provide skills necessary to recognize a crisis and the warning signs of suicide. The program's effect on the participant's general perception, self-efficacy, and attitude towards suicide prevention was examined.

SETTING

Various academic, health care, and professional meetings throughout San Diego County.

PRACTICE INNOVATION

First Question, Persuade, and Refer training program targeting pharmacists.

EVALUATION

A self-administered presurvey, postsurvey and, Program Outcome Evaluation were given to participants of the suicide training program. Items included demographics, general perception, self-efficacy, and attitude toward suicide prevention. Descriptive statistics were used to describe participants' demographics. t tests were used to compare general perception, attitudes, and self-efficacy scores between pretest and post-program evaluation survey responses. Nonparametric Wilcoxon signed rank analyses for matched pairs were used to compare survey responses that asked about attitudes before and after trainings. Regression analyses were conducted to assess factors associated with general perception, self-efficacy, and attitudes.

RESULTS

Participants were more likely to update knowledge after training and reported more confidence to make an intervention for a patient at risk for suicide.

CONCLUSION

Our findings suggest that a suicide prevention training program helped pharmacist respondents build confidence in several self-efficacy areas relating to detection of suicide signs, response to patients with suicidal thoughts, reassurance for patients, and provision of resources and referrals.

Risk of respiratory depression with opioids and concomitant gabapentinoids

INTRODUCTION

The combination of opioids and central nervous system depressants such as benzodiazepines and barbiturates has an additive effect on the frequency of oversedation and respiratory depression requiring naloxone use in hospitalized patients. Gabapentinoids (gabapentin and pregabalin) are frequently prescribed with opioids for their opioid-sparing and adjuvant analgesic effects. There is limited literature on the risk of respiratory depression due to the combination of opioids and gabapentinoids requiring naloxone administration.

METHODS

This retrospective study evaluated patients who were prescribed opioids and at least one dose of naloxone between March 1, 2014 and September 30, 2016. The primary objective of this study was to compare the frequency of respiratory depression among patients who received naloxone and opioids (non-gabapentinoid group) with those who received naloxone, opioids, and gabapentinoids (gabapentinoid group). Secondary objectives included comparing the association of oversedation, using the Pasero Opioid-induced Sedation Scale, and various risk factors with those in the gabapentinoid group.

RESULTS

A total of 153 patient episodes of naloxone administration (102 in the non-gabapentinoid and 51 in the gabapentinoid groups) in 125 unique patients were included in the study. For the primary objective, there were 33 episodes of respiratory depression associated with the non-gabapentinoid group (33/102=32.4%) versus 17 episodes of respiratory depression with the gabapentinoid group (17/51=33.3%) (p=0.128). Secondary objectives showed a significant association between respiratory depression and surgery in the previous 24 hours (p=0.036) as well as respiratory depression and age >65 years (p=0.031) for patients in the non-gabapentinoid group compared to the gabapentinoid group.

CONCLUSION

There was no significant association of respiratory depression in the gabapentinoid group versus the non-gabapentinoid group. There was an increased risk of respiratory depression in the gabapentinoid group, specifically in patients who had surgery within the previous 24 hours.

Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens

Urine drug testing is frequently used in clinical, employment, educational, and legal settings and misinterpretation of test results can result in significant adverse consequences for the individual who is being tested. Advances in drug testing technology combined with a rise in the number of novel misused substances present challenges to clinicians to appropriately interpret urine drug test results. Authors searched PubMed and Google Scholar to identify published literature written in English between 1946 and 2016, using urine drug test, screen, false-positive, false-negative, abuse, and individual drugs of abuse as key words. Cited references were also used to identify the relevant literature. In this report, we review technical information related to detection methods of urine drug tests that are commonly used and provide an overview of false-positive/false-negative data for commonly misused substances in the following categories: cannabinoids, central nervous system (CNS) depressants, CNS stimulants, hallucinogens, designer drugs, and herbal drugs of abuse. We also present brief discussions of alcohol and tricyclic antidepressants as related to urine drug tests, for completeness. The goal of this review was to provide a useful tool for clinicians when interpreting urine drug test results and making appropriate clinical decisions on the basis of the information presented.

Assessment of Burnout and Associated Risk Factors Among Pharmacy Practice Faculty in the United States

Objectives. To measure the level of burnout among pharmacy practice faculty members at US colleges and schools of pharmacy and to identify factors associated with burnout. Methods. Using a cross-sectional, electronic, anonymous survey-design, we measured faculty burnout (n=2318) at US colleges and schools of pharmacy using the Maslach Burnout Inventory-Educators Survey (MBI-ES), which measures burnout dimensions: emotional exhaustion, depersonalization, and personal accomplishment. We assessed MBI-ES scores, demographics and possible predictors of burnout. Results. The response rate was 32.7% (n=758). Emotional exhaustion was identified in 41.3% and was higher in women, assistant professors, and those without a hobby. Participants without a mentor had higher scores of depersonalization. Those with children ages 1-12 years had higher emotional exhaustion and depersonalization compared to those with older children. Conclusion. Pharmacy practice faculty members at US colleges and schools of pharmacy are suffering from burnout, exhibited mainly through emotional exhaustion.

Depression, antidepressants and driving safety

BACKGROUND

The purpose of this study was to review to review the reported associations of depression and antidepressants with motor vehicle crashes.

PURPOSE

A literature search for material published in the English language between January, 1995, and October, 2015, in bibliographic databases was combined with a search for other relevant material referenced in the retrieved articles.

METHODS

Retrieved articles were systematically reviewed for inclusion criteria: 19 epidemiological studies (17 case-control and 2 cohort studies) fulfilled the inclusion criteria by estimating the crash risk associated with depression and/or psychotropic medications in naturalistic settings.

RESULTS

The estimates of the odds ratio (OR) of crash involvement associated with depression ranged from 1.78 to 3.99. All classes of antidepressants were reported to have side effects with the potential to affect driving safety. The majority of studies of antidepressant effects on driving reported an elevated crash risk, and ORs ranged from 1.19 to 2.03 for all crashes, and 3.19 for fatal crashes. In meta-analysis, depression was associated with approximately 2-fold increased crash risk (summary OR = 1.90; 95% CI, 1.06 to 3.39), and antidepressants were associated with approximately 40% increased crash risk (summary OR = 1.40; 95%CI, 1.18 to 1.66).

CONCLUSION

Based on the findings of the studies reviewed, depression, antidepressants or the combination of depression and antidepressants may pose a potential hazard to driving safety. More research is needed to understand the individual contributions of depression and the medications used to treat depression.

A Myoclonic Reaction with Low-Dose Hydromorphone

Objective:

To report a case of myoclonus associated with the use of a low dose of the opioid analgesic hydromorphone.

Case Summary:

A 55-year-old white man with a history of nonobstructive hypertrophic cardiomyopathy was hospitalized for treatment of severe chest pain. On hospital day 1, intravenous hydromorphone (6 doses, total dose of 4 mg) was administered. The pain continued and, on day 2, the dose was increased, with a total of 6 mg administered on day 2. The patient developed uncontrollable jerking movements of the head, neck, arms, and legs after he received the hydromorphone. The myoclonic movements stopped within a few hours following discontinuation of hydromorphone and did not recur.

Discussion:

Myoclonus is a neuroexcitatory symptom that has been reported with chronic, high-dose administration of hydromorphone in patients with impaired renal function. The hydromorphone-3-glucuronide metabolite is devoid of analgesic activity and has been shown to cause neuroexcitatory effects. This patient's symptoms appeared soon after hydromorphone was initiated and resolved in a timely manner after the medication was discontinued. Based on the patient's presentation and course of therapy, it is probable, as indicated by the Naranjo probability scale, that the myoclonic symptoms were induced by hydromorphone. This case was unique, however, in that the patient received hydromorphone for only a short duration and did not have impaired renal function.

Conclusions:

Neuroexcitatory effects of hydromorphone may occur at relatively low doses in patients without renal dysfunction. Early recognition and intervention are required to achieve resolution of these symptoms and prevent further sequelae to the patient.

Operation results of the KSTAR far infrared interferometer

The 2015 KSTAR experimental campaign was the first year of routine measurement with a far infrared interferometer (FIRI) utilizing 118.87 μm CH₃OH lasers at maximum 200 mW CW beam power. By using rtEFIT reconstruction, the path lengths of interferometers can be calculated and so the line-averaged electron densities n¯_e from the FIRI and a millimeter-wave interferometer were in excellent agreement. In this way, the number of successfully diagnosed discharges is counted: 1003 shots or 83.7% of sustained discharges, defined as shots of plasma current I_P ≥ 0.3 MA with pulse lengths t_f ≥ 2.0 s, have good-quality FIRI data within a few fringe jump errors. In addition, real-time H-mode density feedback control based on the FIRI was also successfully achieved with supersonic molecular beam injection as an actuator. Both constant density and controlled linear increment with a ramp-up rate of 1.0 × 10¹⁹ m^-3 s^-1 were achieved.

Neonatal mortality and topical application of chlorhexidine on umbilical cord stump: a meta-analysis of randomized control trials

OBJECTIVE

To examine the efficacy of topical chlorhexidine as an intervention on neonatal umbilical cord stumps and its association with neonatal mortality and omphalitis.

STUDY DESIGN

Meta-analysis of randomized controlled trials (RCTs).

METHOD

PubMed, EMBASE, CINAHL, IMSEAR, Google Scholar, Cochrane Central Register of Controlled Trials, Cochrane Pregnancy and Childbirth Group's Trials Register and Clinicaltrials.gov were screened until September 1, 2015 to identify RCTs that met the inclusion criteria. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated.

RESULTS

Five RCTs, conducted in Italy, Bangladesh, Nepal, Pakistan and India with a total of 55,008 participants were identified. Analysis revealed a significant reduction in the incidence of neonatal mortality among the intervention group as compared to the control group (pooled RR = 0.8; 95% CI: 0.6-1.0; P = 0.04; random effects model, I² = 58%; χ² = 9.5; P = 0.05). Additionally, decreased incidence in omphalitis was seen in the intervention group as compared to the control group (pooled RR = 0.4; 95% CI: 0.3-0.7; P < 0.001; random effects model, I² = 50%; χ² = 8.0; P = 0.09).

CONCLUSIONS

Application of chlorhexidine to newborn umbilical cord stumps, significantly reduce the incidences of both neonatal mortality and omphalitis. However, high-quality trials from different regions and obstetric settings may help form more conclusive judgement on universal application of topical chlorhexidine.

Evaluation of a shared pharmacogenomics curriculum for pharmacy students

Aim: This national dissemination study evaluated pharmacy students’ self-reported overall ability, self-efficacy and attitudes toward applying pharmacogenomics and perceptions of Pharmacogenomics Education Program, a shared pharmacogenomics curriculum. Patients & methods: Following a series of train-the-trainer programs for pharmacy faculty, pre- (n = 2674) and post-training surveys (n = 2542) were administered to Doctor of Pharmacy students (n = 43 pharmacy schools). Results: Students reported increased (pre- vs post-training) overall ability to educate patients about pharmacogenomics (17 vs 63%; p < 0.0001) and pharmacogenomic testing (11 vs 60%; p < 0.0001) and increased self-efficacy for identifying therapeutic areas for which pharmacogenomic testing is required (20 vs 75%; p < 0.0001). Most (92%) agreed that students at other schools would benefit from receiving the same, or similar, pharmacogenomics education. Conclusion: A shared curriculum is an effective approach for broadscale curricular dissemination.

Original submitted 17 October 2014; Revision submitted 19 December 2014

Cardiac transplantation and concomitant coronary artery bypass grafting: our experiences in 11 cases

INTRODUCTION

The shortage of donor hearts for transplantation could be alleviated by including the hearts of older donors. Previous literature revealed similar early and medium-term survival outcomes compared with those of younger donors. This study presents our experience with patients who underwent orthotopic heart transplantation and concomitant coronary artery bypass grafting at our institution.

METHODS

We present our experience with 11 patients with end-stage cardiomyopathy (8 men and 3 women) undergoing orthotopic heart transplantation and concomitant coronary artery bypass grafting from September 2002 to November 2011 at our institute.

RESULTS

All 11 donor organs would otherwise have been rejected, depriving potential recipients of organ transplantation. Two patients received concurrent 2-coronary-artery bypass, and the other 9 patients received concurrent single-coronary-artery bypass during orthotopic heart transplantation. All patients had an uneventful postoperative course, with follow-up completed 3 to 128 months after cardiac transplantation and concomitant coronary artery bypass grafting surgery.

CONCLUSIONS

Our experiences suggest that donor hearts requiring coronary artery bypass grafting, which form a small but significant donor subgroup, can be used effectively and safely when matched to the recipients' age and medical condition.

Development of a pharmacist-psychiatrist collaborative medication therapy management clinic

OBJECTIVE

To describe a needs assessment, practice description, practice innovation and reimbursement of a psychiatric pharmacist medication therapy management (MTM) clinic with related challenges and opportunities.

SETTING

An MTM clinic established in collaboration with the Outpatient Psychiatric Services (OPS) at the University of California San Diego (UCSD), under contract with the San Diego County Health and Human Services Agency Adult and Older Adult Mental Health Services (A/OAMHS).

PRACTICE DESCRIPTION

Two board-certified psychiatric pharmacists provided direct patient care using a collaborative practice protocol 3 days per week. Clinical services included pharmacotherapy management, laboratory monitoring, medication counseling, and psychosocial referrals to other providers.

PRACTICE INNOVATION

Payment to UCSD OPS for clinical services was based on a contract between the San Diego County A/OAMHS and the clinic. Two pharmacists co-managed mental health patients and billed for medication management based on face-to-face contact time (medication minutes) and documentation time with each patient.

MAIN OUTCOME MEASURES

Number of patients comanaged, dropout rates, visit duration, and billed minutes.

RESULTS

From May 2009 to December 2010, two pharmacists comanaged 68 patients, mean (± SD) age 48.6 ± 11.6 years, diagnosed with major depressive, schizophrenic, schizoaffective, and/or bipolar disorder. A total of 56 (82.3%) patients were clinically stable and remained on the pharmacist caseload, but 12 (17.6%) patients were lost to follow-up (10 lost contact, 1 moved, 1 expired). On average, patients had 7.7 patient visits , for 491 total visits (with an average of 26 minutes per visit) that were billed at a rate of $4.82 per minute for medication minutes, translating to $84,542.80.

CONCLUSION

With provider education and appropriate physician champions, pharmacists are able to work collaboratively with psychiatrists in a mental health clinic.

Dose-Related Paresthesias With Venlafaxine

Introduction:

Venlafaxine is a serotonin norepinephrine reuptake inhibitor that is used for mood, anxiety, and pain disorders. We report a case of dose-related paresthesias in association with venlafaxine use in a patient with major depressive disorder. Case report: A young male patient with major depression started treatment with venlafaxine XR at 37.5 mg/d, and the dose was titrated to 75 mg/d with no significant adverse effects. Upon increasing the dose to 150 mg/d, the patient reported tingling, numbness, and itching in his upper extremities. The dose was reduced to 75 mg/d, at which time, the symptoms disappeared. Since the patient still had target symptoms of depression, the patient was willing to try increasing the dose back to 150 mg/d. Upon rechallenge, the tingling, numbness, and itching reappeared. The dose of venlafaxine was decreased back to 75 mg/d. Per the Naranjo scale, the probability score for the above adverse drug reaction is 5 (probable). We discuss the published evidence of paresthesias associated with antidepressants and clinical implications for recognizing paresthesias during venlafaxine treatment that may be useful for clinicians.

Conclusion:

Clinicians need to be aware of the possible emergence of paresthesias with venlafaxine treatment, especially at doses of ≥150 mg/day. Patients who receive venlafaxine for pain disorders should be closely monitored for worsening of pain symptoms and may require adjustment of their doses.

Implementation and outcomes of a live continuing education program on pharmacogenomics

Aim: This study evaluated the implementation and outcomes of a pharmacogenomics education program among pharmacists. Materials & methods: Continuing education lectures were presented at local, state and national pharmacy conferences. Results: Six hundred and seventy three pharmacist participants (mean ± standard deviation: 45 ± 14 years of age with 19 ± 13 years of practice experience) completed program evaluations. Participants’ knowledge and overall ability to address pharmacogenomics testing significantly improved (p < 0.001). More than 50% rated self-efficacy for putting pharmacogenomics knowledge into clinical practice to be likely or very likely. Attitudes toward increasing the number of patients to educate, updating pharmacogenomics knowledge, and providing advice were 39, 76 and 64%, respectively. Participants rated program components to be useful or very useful, and the quality of the program format, program content and audience response system as good, very good or excellent. Conclusion: Through live continuing education presentations at pharmacy conferences, participants showed significant increases in knowledge and their overall ability to address pharmacogenomics testing with patients.

Original submitted 30 January 2013; Revision submitted 10 April 2013

Prevalence, outcome and risk factors for postoperative pyothorax in 232 dogs undergoing thoracic surgery

Objective

To determine the prevalence, outcome and risk factors for postoperative pyothorax in dogs undergoing thoracic surgery.

Methods

Case records were reviewed retrospectively to identify dogs with post thoracic surgery pyothorax, defined as septic neutrophilic inflammation within the pleural space based on cytology and/or a positive bacterial culture of pleural fluid. Those identified were reviewed for potential risk factors for postoperative pyothorax based on biological plausibility and previously published data. These potential risk factors were explored by multivariable logistic regression.

Results

Of 232 dogs undergoing thoracic surgery, 15 (6·5%) dogs developed pyothorax. Bacteria cultured included methicillin-resistant Staphylococcus aureus and multi-resistant Escherichia coli. Of these dogs, six died, four were euthanased and five were treated successfully. A diagnosis of idiopathic chylothorax [Odds Ratio (OR)=12·5, 95% Confidence Interval (CI)=2·7-58·5, P=0·001], preoperative intrathoracic biopsy (OR=14·3, 95% CI=1·7-118·7, P=0·014) and preoperative thoracocentesis (OR=11·2, 95% CI=1·6-78·2, P=0·015) were identified as independent risk factors for development of postoperative pyothorax.

Clinical Significance

Idiopathic chylothorax, intrathoracic biopsy and prior thoracocentesis are independent risk factors for postoperative pyothorax, which was associated with a 67% mortality rate.

Target-controlled infusion of remifentanil for laryngeal mask airway insertion during sevoflurane induction in adults

OBJECTIVE

This randomized, double-blind study investigated the suitable target effect-site concentration of remifentanil for laryngeal mask airway (LMA) insertion during inhalation induction with sevoflurane.

METHODS

Patients aged 18 - 60 years were randomly assigned to one of three groups receiving infusions of normal saline (control group), or infusions with target effect-site remifentanil concentrations of either 1 ng/ml (R1 group) or 2 ng/ml (R2 group), 1 min after the induction of anaesthesia with sevoflurane. LMA insertion was attempted 2 min after induction. Insertion conditions were graded using a six-variable, three-point scale (excellent, intermediate or poor).

RESULTS

A total of 102 patients were included. The proportion of patients ranked as excellent for the LMA insertion was significantly higher in groups R1 and R2 compared with the control group. The incidence of apnoea was significantly more frequent in the R2 group than in the control or R1 groups.

CONCLUSIONS

Compared with 1 ng/ml remifentanil or normal saline, target-controlled infusion of 2 ng/ml remifentanil significantly improved the LMA insertion conditions during sevoflurane inhalational induction, although apnoeic episodes were more frequently observed.

Pharmacotherapy considerations in patients with HIV and psychiatric disorders: focus on antidepressants and antipsychotics

OBJECTIVE

To review the evidence for the efficacy and safety of pharmacologic agents for the treatment of depressive and psychotic disorders in patients with HIV infection and to provide clinical considerations for the treatment of depression and psychosis in these patients.

DATA SOURCES

PubMed was searched for articles published between 1966 and August 1, 2012, using the search terms antiretrovirals, HIV, AIDS, depression, psychosis, schizophrenia, antidepressant, antipsychotic, and individual drug names (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, venlafaxine, duloxetine, mirtazapine, bupropion, haloperidol, perphenazine, fluphenazine, aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone).

STUDY SELECTION AND DATA EXTRACTION

For the purposes of evaluating efficacy data, we limited our selection to randomized placebo-controlled or active comparator-controlled trials for agents that have been used for depression and psychosis in HIV-infected patients.

DATA SYNTHESIS

We found 11 studies for depression treatment and 1 study for psychosis treatment that met our inclusion and exclusion criteria. Selective serotonin reuptake inhibitors (SSRIs; especially fluoxetine) and tricyclic antidepressants appear to be effective in treating depressive symptoms in patients with HIV infection without affecting immune status. Testosterone, stimulants, and dehydroepiandrosterone may also be effective in subsyndromal depression; however, studies on these agents in general were limited by small sample size. There are limited data for antipsychotics, with the only controlled study found for haloperidol and chlorpromazine used for AIDS delirium. Drug-drug interactions and potentiation of metabolic syndrome are concerns for the combined use of antidepressants and antipsychotics with antiretrovirals.

CONCLUSIONS

Larger controlled studies are needed to validate the current findings as well as expand knowledge for non-SSRI antidepressants and second-generation antipsychotics for use in HIV-infected patients.

A train-the-trainer approach to a shared pharmacogenomics curriculum for US colleges and schools of pharmacy

OBJECTIVE

To assess pharmacy faculty trainers' perceptions of a Web-based train-the-trainer program for PharmGenEd, a shared pharmacogenomics curriculum for health professional students and licensed clinicians.

METHODS

Pharmacy faculty trainers (n=58, representing 39 colleges and schools of pharmacy in the United States and 1 school from Canada) participated in a train-the-trainer program consisting of up to 9 pharmacogenomics topics. Posttraining survey instruments assessed faculty trainers' perceptions toward the training program and the likelihood of their adopting the educational materials as part of their institution's curriculum.

RESULTS

Fifty-five percent of faculty trainers reported no prior formal training in pharmacogenomics. There was a significant increase (p<0.001) in self-reported ability to teach pharmacogenomics to pharmacy students after participants viewed the webinar and obtained educational materials. Nearly two-thirds (64%) indicated at least a "good" likelihood of adopting PharmGenEd materials at their institution during the upcoming academic year. More than two-thirds of respondents indicated interest in using PharmGenEd materials to train licensed health professionals, and 95% indicated that they would recommend the program to other pharmacy faculty members.

CONCLUSION

As a result of participating in the train-the-trainer program in pharmacogenomics, faculty member participants gained confidence in teaching pharmacogenomics to their students, and the majority of participants indicated a high likelihood of adopting the program at their institution. A Web-based train-the-trainer model appears to be a feasible strategy for training pharmacy faculty in pharmacogenomics.

Multipulse addressing of a Raman quantum memory: configurable beam splitting and efficient readout

Quantum memories are vital to the scalability of photonic quantum information processing (PQIP), since the storage of photons enables repeat-until-success strategies. On the other hand, the key element of all PQIP architectures is the beam splitter, which allows us to coherently couple optical modes. Here, we show how to combine these crucial functionalities by addressing a Raman quantum memory with multiple control pulses. The result is a coherent optical storage device with an extremely large time bandwidth product, that functions as an array of dynamically configurable beam splitters, and that can be read out with arbitrarily high efficiency. Networks of such devices would allow fully scalable PQIP, with applications in quantum computation, long distance quantum communications and quantum metrology.

Clinical Application of Pharmacogenomics

The purpose of this review is to discuss the clinical application of pharmacogenomics for select drug therapies (eg, proton pump inhibitors [PPIs], codeine, and carbamazepine) and to highlight limitations and challenges that preclude implementation of pharmacogenomics into clinical practice. Genetic polymorphisms of cytochrome P450 (CYP) enzymes and the presence of the human leukocyte antigen ( HLA) -B*1502 allele influence drug disposition and/or response. A portion of PPI pharmacokinetic and pharmacodynamic variability can be explained by CYP2C19 genotype. However, conflicting evidence exists related to Helicobacter pylori cure rates based on CYP2C19 genotype. For codeine, adverse drug reactions in neonates through breast-feeding from CYP2D6 ultra-rapid metabolizers have been reported. However, there is lack of conclusive evidence regarding the overall influence of CYP2D6 polymorphisms on codeine efficacy and toxicity. Although CYP2C19 and CYP2D6 genotyping tests are available, clinical utility remains low. The presence of the HLA-B*1502 allele is associated with carbamazepine-induced Stevens-Johnson syndrome (SJS) and/or toxic epidermal necrolysis (TEN). Pharmacogenomic testing is required prior to initiating carbamazepine in high-risk patients. Lack of sufficient resources, provider knowledge, and ethical, legal, and social issues are several limitations and challenges to implementing pharmacogenomic testing in clinical practice.

Pharmacogenomics of antidepressants for major depressive disorder

Major depressive disorder (MDD) is a common disorder, affecting approximately 10% of adults in the United States each year. The primary treatment options for moderate to severe MDD are antidepressant medications, mainly selective serotonin reuptake inhibitors (SSRIs). Current guidelines recommend an initial trial of 4–8 weeks to determine if a medication is effective for a patient. Through the use of pharmacogenomics, it may be possible to predict whether patients will respond to and tolerate SSRIs. This article discusses several genes and alleles that may play a role in a patient's response to SSRIs.

Single-photon-level quantum memory at room temperature

Room-temperature, easy-to-operate quantum memories are essential building blocks for future long distance quantum information networks operating on an intercontinental scale, because devices like quantum repeaters, based on quantum memories, will have to be deployed in potentially remote, inaccessible locations. Here we demonstrate controllable, broadband and efficient storage and retrieval of weak coherent light pulses at the single-photon level in warm atomic cesium vapor using the robust far off-resonant Raman memory scheme. We show that the unconditional noise floor of this technically simple quantum memory is low enough to operate in the quantum regime, even in a room-temperature environment.

Institutional Profile: University of California San Diego Pharmacogenomics Education Program (PharmGenEd™): bridging the gap between science and practice

Clinical application of evidence-based pharmacogenomics information has the potential to help healthcare professionals provide safe and effective medication management to patients. However, there is a gap between the advances of pharmacogenomics discovery and the health professionals' knowledge regarding pharmacogenomics testing and therapeutic uses. Furthermore, pharmacogenomics education materials for healthcare professionals have not been readily available or accessible. Pharmacogenomics Education Program (PharmGenEd™) is an evidence-based pharmacogenomics education program developed at the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences and the School of Medicine (CA, USA), with funding support from the Centers for Disease Control and Prevention. Program components include continuing education modules, train-the-trainer materials and shared curriculum modules based on therapeutic topics, and virtual communities with online resources.

Density gradient stabilization of electron temperature gradient driven turbulence in a spherical tokamak

In this Letter we report the first clear experimental observation of density gradient stabilization of electron temperature gradient driven turbulence in a fusion plasma. It is observed that longer wavelength modes, k(⊥)ρ(s) ≲ 10, are most stabilized by density gradient, and the stabilization is accompanied by about a factor of 2 decrease in the plasma effective thermal diffusivity.

BAG3-related myofibrillar myopathy in a Chinese family

In contrast to the usual slow disease progression in myofibrillar myopathies, patients with Bag3opathy often have a rapidly progressive and more severe phenotype with a worse prognosis. We describe a Chinese patient, born to non-consanguineous parents, who first presented at age 6 with clumsy walking and difficult climbing staircase. With a history of restrictive lung disease previously diagnosed as asthma, she progressed rapidly with proximal myopathy, rigid spine and bilateral tightening of the Achilles tendons requiring surgical elongation. Hypertrophic cardiomyopathy with restrictive physiology was shown by echocardiogram. Moreover, prolonged QT interval was also noted in the patient. Family history was unremarkable yet her father was incidentally found to have prolonged QT interval. Mutation analysis with genomic DNA of the proband showed heterozygous de novo known mutation c.626C>T (p.Pro209Leu) and a germline variation c.772C>T (p.Arg258Trp) in BAG3. Her father was found to be a carrier of c.772C>T. Muscle biopsy findings were suggestive of myofibrillar myopathy on light microscopy and ultrastructural studies. To our knowledge, this is the first Chinese case of Bag3opathy so far reported.

HLA-B*5701 testing to predict abacavir hypersensitivity

Abacavir is a nucleoside reverse transcriptase inhibitor used for combination antiretroviral therapy for treating human immunodeficiency virus (HIV) infection. An adverse effect from abacavir is a treatment-limiting hypersensitivity reaction, which can be severe and potentially life-threatening. Abacavir-induced hypersensitivity reaction has been associated with the presence of the major histocompatibility complex class I allele HLA-B*5701. A screening test for the HLA-B*5701 allele can assist clinicians to identify patients who are at risk of developing a hypersensitivity reaction to abacavir.

NSTX far infrared tangential interferometer/polarimeter electronics upgrade

New electronics for the multichannel far infrared tangential interferometer/polarimeter system employed on the National Spherical Torus Experiment (NSTX) have greatly extended its capability to monitor high frequency density fluctuations. Such measurements are essential in understanding transport physics issues in NSTX as well as for the coming ITER device. The electronics, which were previously limited to ∼250 kHz, have been upgraded with a video bandwidth that extends to 4 MHz when operating as an interferometry-only configuration, and to ∼500 kHz when operating as a simultaneous interferometer/polarimeter system. Experimental details and test results of the new electronics are presented.

Use of the Far Infrared Tangential Interferometer/Polarimeter diagnostic for the study of rf driven plasma waves on NSTX

A rf detection system for waves in the 30 MHz range has been constructed for the Far Infrared Tangential Interferometer/Polarimeter on National Spherical Torus Experiment (NSTX). It is aimed at monitoring high frequency density fluctuations driven by 30 MHz high harmonic fast wave fields. The levels of density fluctuations at various radial chords and antenna phase angles can be estimated using the electric field calculated by TORIC code and linearized continuity equation for the electron density. In this paper, the experimental arrangement for the detection of rf signal and preliminary results of simulation will be discussed.

Fringe-jump corrected far infrared tangential interferometer/polarimeter for a real-time density feedback control system of NSTX plasmas

The far infrared tangential interferometer/polarimeter (FIReTIP) of the National Spherical Torus Experiment (NSTX) has been set up to provide reliable electron density signals for a real-time density feedback control system. This work consists of two main parts: suppression of the fringe jumps that have been prohibiting the plasma density from use in the direct feedback to actuators and the conceptual design of a density feedback control system including the FIReTIP, control hardware, and software that takes advantage of the NSTX plasma control system (PCS). By investigating numerous shot data after July 2009 when the new electronics were installed, fringe jumps in the FIReTIP are well characterized, and consequently the suppressing algorithms are working properly as shown in comparisons with the Thomson scattering diagnostic. This approach is also applicable to signals taken at a 5 kHz sampling rate, which is a fundamental constraint imposed by the digitizers providing inputs to the PCS. The fringe jump correction algorithm, as well as safety and feedback modules, will be included as submodules either in the gas injection system category or a new category of density in the PCS.

Triggered confinement enhancement and pedestal expansion in high-confinement-mode discharges in the national spherical torus experiment

We report observation of a new high performance regime in discharges in the National Spherical Torus Experiment, where the H mode edge "pedestal" temperature doubles and the energy confinement increases by 50%. The spontaneous transition is triggered by a large edge-localized mode, either natural or externally triggered by 3D fields. The transport barrier grows inward from the edge, with a doubling of both the pedestal pressure width and the spatial extent of steep radial electric field shear. The dynamics suggest that 3D fields could be applied to reduce edge transport in fusion devices.

Strong purified protein derivative responses are associated with poor mycobacterium inhibition in latent TB

The tuberculin skin test (TST) using purified protein derivative (PPD) of Mycobacterium tuberculosis is traditionally used to diagnose latent tuberculosis (TB) infection (LTBI). However, LTBI diagnosis by peripheral blood mononuclear cell (PBMC) interferon (IFN)-gamma responses to M. tuberculosis-specific antigens, early secreted antigenic target 6 kDa (ESAT-6) and culture filtrate protein (CFP)-10 has greater specificity. We investigated the difference in antimycobacterium cellular immunity in TB contacts who were strong TST reactors but nonresponsive to the ESAT-6/CFP-10 assay compared with those with concordant results. Healthy TB contacts were tested using the above two assays and mycobacterium survival was measured after co-culture of infected macrophages with their PBMCs. Whether PPD reactivity was tested by TST or by PBMC-specific IFN-gamma responses, strongly PPD-reactive TB contacts without ESAT-6/CFP-10 responsiveness showed significantly better mycobacterium inhibition activity than ESAT-6/CFP-10-responsive TB contacts with the same PPD reactivity. In the former group, stronger PPD reactivity was associated with improved mycobacterium killing, whereas ESAT-6/CFP-10 responders showed the opposite result. PPD-reactive ESAT-6/CFP-10-nonresponsive TB contacts in our population may have had protective immunity related to prior mycobacterium exposure. ESAT-6/CFP10-responsive TB contacts are more likely to have LTBI and, in this group, strong PPD reactivity may paradoxically be associated with poor mycobactericidal activity.