Nebulized medications in the emergency department: A narrative review of nontraditional agents.

PURPOSE: This article summarizes emerging nontraditional therapies administered via the nebulization route for use in the emergency department (ED). SUMMARY: Although traditional routes of medication administration (eg, intravenous) have been the mainstay of administration modalities for decades, these routes may not be appropriate for all patients. Nowhere is this more readily apparent than in the ED setting, where patients with a variety of presentations receive care. One unique route for medication administration that has increasingly gained popularity in the ED is that of aerosolized drug delivery. This route holds promise as direct delivery of medications to the site of action could yield a more rapid and effective therapeutic response while also minimizing systemic adverse effects by utilizing a fraction of the systemic dose. Medication administration via nebulization also provides an alternative that is conducive to rapid, less invasive access, which is advantageous in the emergent setting of the ED. This review is intended to analyze the existing literature regarding this route of administration, including the nuances that can impact drug efficacy, as well as the available literature regarding novel, noncommercial nebulized medication therapy given in the ED. CONCLUSION: Multiple medications have been investigated for administration via this route, and when implementing any of these therapies several practical considerations must be taken into account, from medication preparation to administration, to ensure optimal efficacy while minimizing adverse effects. The pharmacist is an essential bedside team member in these scenarios to assist with navigating unique and complex nuances of this therapy as they develop.

Partnerships to Facilitate Total Force Fitness.

Total force fitness (TFF) is a multi-domain framework designed to assess, promote, and sustain human performance optimization across a service member's career arc. During the September 2021, TFF Summit sponsored by the Consortium for Health and Military Performance (CHAMP), a working group explored partnerships that could facilitate effective implementation and sustainment of TFF principles. Many potential partners were identified, both internal and external to the DoD. This report highlights some positions and organizations that provide the highest yield for successfully inculcating TFF across the services.

Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study.

INTRODUCTION: Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists. OBJECTIVE: This study aimed to explore dentists' approach to treatment decision-making with or for PLwD. METHODS: Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD. RESULTS: Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family. CONCLUSIONS: Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort. KNOWLEDGE TRANSFER STATEMENT: This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.

Dental care for people living with dementia: current challenges and planning for the future. The UK perspective.

Dementia is a major public health challenge, and its impact on oral health and oral healthcare delivery can be drastic. More people are living with dementia, and the proportion of people living longer is growing. This review summarises dementia and its impact on oral health, dental care access and dental services. People living with dementia (PLwD) face a substantial risk of developing oral diseases and experiencing orofacial pain. PLwD face many barriers to dental care. When care is accessed, there can be practical and ethical challenges in receiving person-centred treatment. PLwD with the most complex needs are increasing in number and more are likely to require specialist care. Recommendations are made regarding preventative care, dental care access, domiciliary care, workforce planning and treatment decision-making. Those commissioning and facilitating dental care for PLwD should ensure that suitably trained staff are available in accessible services to plan the necessary care and provide active treatment where appropriate. It is almost inevitable that more care will need to be commissioned to support this growing patient group. This need should be anticipated and planned for at a population and policy level to reduce the detrimental impacts of oral diseases and orofacial pain for PLwD.

Increased Prevalence of Overweight and Obesity and Incidence of Prediabetes and Type 2 Diabetes During the COVID-19 Pandemic, Active Component Service Members, U.S. Armed Forces, 2018 to 2021

This study evaluated trends in the prevalence of overweight, obesity, and diabetes among active component service members between 2018 and 2021, before and after the start of the COVID-19 pandemic. This study also investigated the incidence of prediabetes and type 2 diabetes mellitus (T2DM) diagnoses during the same period. Between 2018 and 2021, the prevalence of obesity among active component service members who completed a Periodic Health Assessment (PHA) increased from 16.1% to 18.8%. The incidence of prediabetes increased from 588.2 to 763.8 cases per 100,000 person-years (p-yrs), and the incidence of T2DM increased from 55.5 to 69.6 per 100,000 p-yrs. The largest relative increases in obesity prevalence were in the youngest (<30 years) age categories. Navy members and Hispanic service members experienced the largest absolute and relative increases in rates of new diabetes diagnoses. These findings indicate that during the COVID-19 pandemic active component service members experienced increased prevalence of obesity, prediabetes, and diabetes. Evaluation of lifestyle factors associated with these chronic diseases among service members may be useful to enhance deployment readiness and operational effectiveness.

Intranasal Dexmedetomidine Use in Pediatric Patients for Anxiolysis in the Emergency Department.

OBJECTIVES: In recent years, dexmedetomidine has gained traction as a treatment for anxiolysis in the emergency department (ED). When used with an atomizer, it may also be given intranasally for anxiolysis. The primary objective was to determine the level of ED provider satisfaction and comfort with intranasal (IN) dexmedetomidine for anxiolysis in pediatric patients with behavioral agitation and/or acute psychosis. The secondary objectives included determining safety, rates of therapy failure, and ED length of stay compared with oral midazolam. The efficacy of IN dexmedetomidine versus oral midazolam in patients with autism spectrum disorder (ASD) was also evaluated. METHODS: This was a single-center, prospective study in a pediatric ED from March 1 to December 31, 2021. Patients were included in the study if the ED provider requested IN dexmedetomidine anxiolysis and completed a postadministration survey. Safety and efficacy outcomes were assessed by chart review and compared with patients who received oral midazolam during the same study period. Efficacy was defined as the rate of treatment failure, as the need for procedural termination, progression to procedural sedation, or the requirement of additional medications for anxiolysis. RESULTS: Sixty-two patients received IN dexmedetomidine {median dose [interquartile range (IQR)] of 3.05 [2.04-4.00] µg/kg/dose} compared with 58 who received oral midazolam [median (IQR) dose of 0.29 (0.25-0.48) mg/kg/dose). Providers reported high comfort and satisfaction scores, with median (IQR) scores of 90 (75-100) and 88 (60-100) of 100. Twenty-nine percent of patients experienced treatment failure, most commonly because of the need for additional medications. Those who received IN dexmedetomidine had a longer ED length of stay (6.0 vs 4.4 hours, P = 0.010). Among the patients with ASD, those who received IN dexmedetomidine had a lower rate of treatment failure compared with oral midazolam (21.2% vs 66.7%, P = 0.039). CONCLUSIONS: This study demonstrates that IN dexmedetomidine has high levels of provider comfort and satisfaction, moderately high success rate, and a promising safety profile. In addition, IN dexmedetomidine may be superior to oral midazolam in patients with ASD for anxiolysis, but additional studies are needed.

Baseline Sequencing Surveillance of Public Clinical Testing, Hospitals, and Community Wastewater Reveals Rapid Emergence of SARS-CoV-2 Omicron Variant of Concern in Arizona, USA.

The adaptive evolution of SARS-CoV-2 variants is driven by selection for increased viral fitness in transmissibility and immune evasion. Understanding the dynamics of how an emergent variant sweeps across populations can better inform public health response preparedness for future variants. Here, we investigated the state-level genomic epidemiology of SARS-CoV-2 through baseline genomic sequencing surveillance of 27,071 public testing specimens and 1,125 hospital inpatient specimens diagnosed between November 1, 2021, and January 31, 2022, in Arizona. We found that the Omicron variant rapidly displaced Delta variant in December 2021, leading to an "Omicron surge" of COVID-19 cases in early 2022. Wastewater sequencing surveillance of 370 samples supported the synchronous sweep of Omicron in the community. Hospital inpatient COVID-19 cases of Omicron variant presented to three major hospitals 10.51 days after its detection from public clinical testing. Nonsynonymous mutations in nsp3, nsp12, and nsp13 genes were significantly associated with Omicron hospital cases compared to community cases. To model SARS-CoV-2 transmissions across the state population, we developed a scalable sequence network methodology and showed that the Omicron variant spread through intracounty and intercounty transmissions. Finally, we demonstrated that the temporal emergence of Omicron BA.1 to become the dominant variant (17.02 days) was 2.3 times faster than the prior Delta variant (40.70 days) or subsequent Omicron sublineages BA.2 (39.65 days) and BA.5 (35.38 days). Our results demonstrate the uniquely rapid sweep of Omicron BA.1. These findings highlight how integrated public health surveillance can be used to enhance preparedness and response to future variants. IMPORTANCE SARS-CoV-2 continues to evolve new variants throughout the pandemic. However, the temporal dynamics of how SARS-CoV-2 variants emerge to become the dominant circulating variant is not precisely known. Genomic sequencing surveillance offers unique insights into how SARS-CoV-2 spreads in communities and the lead-up to hospital cases during a surge. Specifically, baseline sequencing surveillance through random selection of positive diagnostic specimens provides a representative outlook of the virus lineages circulating in a geographic region. Here, we investigated the emergence of the Omicron variant of concern in Arizona by leveraging baseline genomic sequence surveillance of public clinical testing, hospitals, and community wastewater. We tracked the spread and evolution of the Omicron variant as it first emerged in the general public, and its rapid shift in hospital admissions in the state health system. This study demonstrates the timescale of public health preparedness needed to respond to an antigenic shift in SARS-CoV-2.

Brown recluse spider envenomation with systemic loxoscelism and delayed hemolysis: A case report.

The brown recluse spider (Loxosceles reclusa) is endemic to the South, West and Central Midwestern United States, and envenomation from this spider can cause cutaneous and/or systemic symptoms. We present a case of systemic loxocelism in an adolescent male resulting in three emergency department visits and two hospitalizations for a rare case of delayed hemolysis 6 days after envenomation. A 19-year-old male presented to the emergency department twice within two days after envenomation with worsening pain, subjective fever, chills, nausea and vomiting. He required a two-day hospitalization for rhabdomyolysis and acute kidney injury. The patient was discharged with improving symptoms and laboratory results on day four before returning again on day seven with worsening symptoms. He was diagnosed with hemolytic anemia on day seven and was subsequently hospitalized for six days. This case of systemic loxoscelism manifested hemolysis six days after envenomation, following an improvement in symptoms and laboratory studies. This case highlights the need for continuous monitoring and/or follow-up in cases of systemic loxocelism.

I Believe I Can Try: Self-Efficacy, Pandemic Behaviors, Coping, and Learning.

While colleges and universities grapple with delivering instruction face-to-face during the pandemic, there is still a lot to learn from remote teaching experiences. The present study aimed to predict self-reported learning during the first year of the pandemic. Building on previous scholarship on the topic, we focus on the moderating effects of self-efficacy, and the mediating effects of coping styles on the relationship between stress and self-reported learning experiences. We also included self-perceptions of class effort, the instructor, and changes in class, personal, professor, and health behaviors. Students (N = 272) in Introductory Psychology classes participated in an online survey as part of a class research requirement. Analyses demonstrated that self-efficacy predicted differences in many measures associated with learning and predicted learning over and above all other variables entered in a hierarchical regression. The relationship between stress and learning was mediated by coping, but not moderated by self-efficacy. These results suggest student beliefs about their ability to perform online are important to learning outcomes, but coping mechanisms mediate the relationship of stress and learning. Especially while teaching during pandemic times using different modalities, instructors will do well to directly address students' perceptions of their own ability and build self-efficacy.

Solvothermal synthesis of soluble, surface modified anatase and transition metal doped anatase hybrid nanocrystals.

Titanium dioxide, or titania, is perhaps the most well-known and widely studied photocatalytic material, with myriad applications, due to a high degree of tunability achievable through the incorporation of dopants and control of phase composition and particle size. Many of the applications of titanium dioxide require particular forms, such as gels, coatings, or thin films, making the development of hybrid solution processable nanoparticles increasingly attractive. Here we report a simple solvothermal route to highly dispersible anatase phase titanium dioxide hybrid nanoparticles from amorphous titania. Solvothermal treatment of the amorphous titania in trifluoroacetic acid leads to the formation of anatase phase nanoparticles with a high degree of size control and near complete surface functionalisation. This renders the particles highly dispersible in simple organic solvents such as acetone. Dopant ions may be readily incorporated into the amorphous precursor by co-precipitation, with no adverse effect on subsequent crystallisation and surface modification.

Utilizing digital predictive biomarkers to identify Veteran suicide risk.

Veteran suicide is one of the most complex and pressing health issues in the United States. According to the 2020 National Veteran Suicide Prevention Annual Report, since 2018 an average of 17.2 Veterans died by suicide each day. Veteran suicide risk screening is currently limited to suicide hotlines, patient reporting, patient visits, and family or friend reporting. As a result of these limitations, innovative approaches in suicide screening are increasingly garnering attention. An essential feature of these innovative methods includes better incorporation of risk factors that might indicate higher risk for tracking suicidal ideation based on personal behavior. Digital technologies create a means through which measuring these risk factors more reliably, with higher fidelity, and more frequently throughout daily life is possible, with the capacity to identify potentially telling behavior patterns. In this review, digital predictive biomarkers are discussed as they pertain to suicide risk, such as sleep vital signs, sleep disturbance, sleep quality, and speech pattern recognition. Various digital predictive biomarkers are reviewed and evaluated as well as their potential utility in predicting and diagnosing Veteran suicidal ideation in real time. In the future, these digital biomarkers could be combined to generate further suicide screening for diagnosis and severity assessments, allowing healthcare providers and healthcare teams to intervene more optimally.

Advances in e-learning in undergraduate clinical medicine: a systematic review.

BACKGROUND: E-learning is recognised as a useful educational tool and is becoming more common in undergraduate medical education. This review aims to examine the scope and impact of e-learning interventions on medical student learning in clinical medicine, in order to aid medical educators when implementing e-learning strategies in programme curricula. METHODS: A systematic review compliant with PRISMA guidelines that appraises study design, setting and population, context and type of evaluations. Specific search terms were used to locate articles across nine databases: MEDLINE/PubMed, ScienceDirect, EMBASE, Cochrane Library, ERIC, Academic Search Complete, CINAHL, Scopus and Google Scholar. Only studies evaluating e-learning interventions in undergraduate clinical medical education between January 1990 and August 2021 were selected. Of the 4,829 papers identified by the search, 42 studies met the inclusion criteria. RESULTS: The 42 studies included varied in scope, cognitive domain, subject matter, design, quality and evaluation. The most popular approaches involved multimedia platforms (33%) and case-based approaches (26%), were interactive (83%), asynchronous (71%) and accessible from home (83%). Twelve studies (29%) evaluated usability, all of which reported positive feedback. Competence in use of technology, high motivation and an open attitude were key characteristics of successful students and preceptors. CONCLUSIONS: Medical education is evolving consistently to accommodate rapid changes in therapies and procedures. In today's technologically adept world, e-learning is an effective and convenient pedagogical approach for the teaching of undergraduate clinical medicine.

SARS-CoV-2 Delta Variant N Gene Mutations Reduce Sensitivity to the TaqPath COVID-19 Multiplex Molecular Diagnostic Assay.

As the SARS-CoV-2 virus evolves, mutations may result in diminished sensitivity to qRT-PCR diagnostic assays. We investigated four polymorphisms circulating in the SARS-CoV-2 Delta lineage that result in N gene target failure (NGTF) on the TaqPath COVID-19 Combo Kit. These mutations were detected from the SARS-CoV-2 genome sequences that matched with the diagnostic assay results of saliva specimens. Full length N genes from the samples displaying NGTF were cloned into plasmids and assayed using three SARS-CoV-2 qRT-PCR assays. These constructs resulted in reduced sensitivity to the TaqPath COVID-19 Combo Kit compared to the controls (mean Ct differences of 3.06, 7.70, 12.46, and 14.12), but were detected equivalently on the TaqPath COVID-19 Fast PCR Combo 2.0 or CDC 2019_nCoV_N2 assays. This work highlights the importance of genomic sequencing to monitor circulating mutations and provide guidance in improving diagnostic assays.

Antimicrobial therapies for prevention of recurrent acute exacerbations of COPD (AECOPD): beyond the guidelines.

BACKGROUND: Unfortunately, many COPD patients continue to exacerbate despite good adherence to GOLD Class D recommended therapy. Acute exacerbations lead to an increase in symptoms, decline in lung function and increased mortality rate. The purpose of this review is to do a literature search for any prophylactic anti-microbial treatment trials in GOLD class D patients who 'failed' recommended therapy and discuss the role of COPD phenotypes, lung and gut microbiota and co-morbidities in developing a tailored approach to anti-microbial therapies for high frequency exacerbators. MAIN TEXT: There is a paucity of large, well-conducted studies in the published literature to date. Factors such as single-centre, study design, lack of well-defined controls, insufficient patient numbers enrolled and short follow-up periods were significant limiting factors in numerous studies. One placebo-controlled study involving more than 1000 patients, who had 2 or more moderate exacerbations in the previous year, demonstrated a non-significant reduction in exacerbations of 19% with 5 day course of moxifloxacillin repeated at 8 week intervals. In Pseudomonas aeruginosa (Pa) colonised COPD patients, inhaled antimicrobial therapy using tobramycin, colistin and gentamicin resulted in significant reductions in exacerbation frequency. Viruses were found to frequently cause acute exacerbations in COPD (AECOPD), either as the primary infecting agent or as a co-factor. However, other, than the influenza vaccination, there were no trials of anti-viral therapies that resulted in a positive effect on reducing AECOPD. Identifying clinical phenotypes and co-existing conditions that impact on exacerbation frequency and severity is essential to provide individualised treatment with targeted therapies. The role of the lung and gut microbiome is increasingly recognised and identification of pathogenic bacteria will likely play an important role in personalised antimicrobial therapies. CONCLUSION: Antimicrobial therapeutic options in patients who continue to exacerbate despite adherence to guidelines-directed therapy are limited. Phenotyping patients, identification of co-existing conditions and assessment of the microbiome is key to individualising antimicrobial therapy. Given the impact of viruses on AECOPD, anti-viral therapeutic agents and targeted anti-viral vaccinations should be the focus of future research studies.

Exploring Associations Between Self-Compassion, Self-Criticism, Mental Health, and Quality of Life in Adults with Cystic Fibrosis: Informing Future Interventions.

Self-compassion is increasingly recognised as an important and beneficial factor in quality of life and mental health-related research, but research within the adult cystic fibrosis (CF) population is scarce. In a cross-sectional study, 114 (56 female, 58 male) adults with CF completed and returned a series of validated questionnaires that assessed CF-related quality of life, negative emotional states (depression, anxiety and stress), self-compassion, and self-criticism. Quality of life and self-compassion were positively correlated, and each in turn were inversely correlated with negative emotional states and self-criticism. Negative emotional states correlated positively to self-criticism. Self-compassion and/or self-criticism moderated ten relationships between various sub-domains of quality of life and negative emotions. Psychological interventions that increase self-compassion may be beneficial for enhancing mental health and quality of life for adults with CF.

Intravenous phytonadione administered orally in reducing warfarin-related coagulopathy.

INTRODUCTION: The cost of phytonadione tablets has increased markedly and is significantly higher than the intravenous formulation. The intravenous formulation given orally is a potential alternative but has not been directly evaluated in comparison to the commercially available tablet. The objective of this study was to evaluate the efficacy of phytonadione intravenous solution given orally compared to commercially available phytonadione tablets for reversal of coagulopathy related to warfarin. METHODS: We conducted a retrospective, observational study of adult patients who received phytonadione tablets and the IV formulation orally for warfarin-related coagulopathy. The international normalized ratio (INR) was measured before and after phytonadione administration. The primary outcome was INR <1.5 at 24 h after phytonadione administration. RESULTS: From January 1, 2015 to August 1, 2018 a total of 200 patients were identified. In total, 58% (n = 116) patients received IV phytonadione solution given orally and 42% (n = 84) patients received the tablets. The primary outcome of INR <1.5 at 24 h was not significantly different between groups (p = 0.321). DISCUSSION: The IV phytonadione solution given by mouth and the tablet formulation performed similarly.