Empirical legal analysis simplified: reducing complexity through automatic identification and evaluation of legally relevant factors.

This paper investigates the potential for reducing the complexity of AI and Law and empirical legal studies projects through a novel annotation methodology that relies on GPT Family Models to assist human annotators. Improving the speed, cost and quality of annotation could greatly benefit such projects. In modelling types of legal claims, researchers in the fields of empirical legal studies and AI and Law have long relied on manually annotating factors in case texts. To demonstrate our methodology, we employ cases and factors regarding whether a police officer has constitutional authority to detain a motorist on the basis of the officer's suspicion that the motorist is trafficking drugs. Our results demonstrate how recent advances in text analytics can reduce the burden of identifying factors in large numbers of cases and improve machine learning models' predictions of case outcomes. This article is part of the theme issue 'A complexity science approach to law and governance'.

High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study.

BACKGROUND: Sympathetic crashing acute pulmonary edema (SCAPE) is a medical emergency in which severe, acute elevation in blood pressure results in acute heart failure and fluid accumulation in the lungs. Without prompt recognition and treatment, the condition often progresses rapidly to respiratory failure necessitating intubation and intensive care unit (ICU) admission. In addition to non-invasive positive pressure ventilation (NIPPV), high-dose nitroglycerin (HDN) has become a mainstay of treatment; however, an optimal dosing strategy has not been established. OBJECTIVE: The purpose of this study was to describe the characteristics and outcomes of patients who received an HDN infusion (≥ 100 µg/min) for the management of SCAPE in the Emergency Department (ED) of a large urban academic medical center. Outcomes were also analyzed to determine predictors of safety and efficacy including use of adjunct medication therapies. RESULTS: There were 67 adult patients who received HDN infusion for SCAPE from January 1, 2018 to December 31, 2018. The median (IQR) systolic blood pressure (SBP) on initiation of HDN infusion was 211 (192-233) mmHg. Patients were 63% male, 84% black, 51% had a history of heart failure (HF), and 36% had end-stage renal disease (ESRD). IV nitroglycerin (NTG) was initiated at a median (IQR) dose of 100 (100-200) mcg/min with median (IQR) peak rate in the first hour of 200 (127.5-200) mcg/min and an absolute maximum observed rate of 400 µg/min overall. 73% of patients received NIPPV, 48% sublingual (SL) or IV bolus nitroglycerin before HDN infusion, 58% loop diuretic, and 34% angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB). Rates of ICU admission, intubation, acute kidney injury (AKI) at 48 h, and hypotension were 37%, 21%, 13%, and 4% respectively. CONCLUSION: This is the largest to date study describing the use of an HDN infusion (≥100 µg/min) strategy for the management of SCAPE. HDN infusion may be a safe alternative strategy to intermittent bolus HDN.

Evaluation of Ketamine for Excited Delirium Syndrome in the Adult Emergency Department.

BACKGROUND: Excited delirium syndrome (ExDS) is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction. A guideline for ExDS management, which recommends the use of ketamine as a second-line agent, was implemented in our hospital's adult emergency department (ED). OBJECTIVE: The primary objective was to determine whether ketamine, 1 mg/kg intravenous (i.v.) or 2 mg/kg intramuscular (i.m.), is being used according to the ExDS guideline. Secondary objectives included evaluating the specific agents, routes, and dosages used to manage ExDS and the safety and efficacy of ketamine. METHODS: Single-center, retrospective chart review of patients who received ketamine for the management of ExDS in the ED. Efficacy was measured by documented Richmond Agitation Sedation Scale (RASS) scores. Safety was assessed through evaluation of vital signs and adverse effects. RESULTS: Thirty-one patients met inclusion criteria. Eight (25.8%) of them received ketamine for ExDS in adherence with all aspects of the guideline. Administration of ketamine led to a statistically significant decrease in median RASS score of 4 (interquartile range [IQR] 3 to 4) vs. 0 (IQR 2 to -1) (p = 0.001). There were no statistically significant differences in vital signs or RASS scores in our subgroup analyses of patients treated according to protocol and of those treated with ketamine, 2 mg/kg i.m. CONCLUSIONS: We found discordance between current practice and our department's ExDS guideline for patients managed with ketamine. Despite the lack of adherence to departmental guidelines and allowing for limitations of this analysis due to small sample size, the use of low-dose, 1 mg/kg i.v. or 2 mg/kg i.m., ketamine was effective and appears to be a reasonable option as second-line therapy for ExDS.

Case report of capecitabine toxicity and use of uridine triacetate.

Fluorouracil and capecitabine are fluoropyrimidine chemotherapy agents that are commonly used for various cancers. These agents are generally well tolerated at standard doses; however, it has been reported that 31-34% of patients develop dose-limiting toxicities. Dihydropyrimidine dehydrogenase and thymidylate synthase play a major role in fluorouracil and capecitabine activity and toxicity. Uridine triacetate has shown promising results for the emergency treatment of patients who either receive an overdose of the cancer treatment fluorouracil or capecitabine or to treat patients who exhibit early-onset, severe, or life-threatening toxicity. We describe a case of a patient who developed capecitabine toxicity and was unsuccessfully treated with uridine triacetate.

Frequency of ß-Blocker Use Following Exacerbations of COPD in Patients with Compelling Indication for Use.

OBJECTIVE: To assess the current use of ß-blockers in patients with compelling indications for use, following the acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: We performed a multicenter retrospective observational study using data from all of the patients admitted to five institutions for an acute exacerbation of COPD. Patients were included if they were admitted for an acute exacerbation of COPD and had a compelling indication for the use of a ß-blocker, defined as previous myocardial infarction or heart failure with left ventricular ejection fraction ≤40%. RESULTS: There were 396 patients meeting the criteria for inclusion in the study. The population was predominantly white men with myocardial infarction as the most prevalent compelling indication. On admission, 267 (67.4%) patients were receiving ß-blockers, which increased to 278 (70.2%) at discharge. There were 118 (29.8%) patients discharged without ß-blockers. Of the predictors tested, none were significantly predictive of a patient not receiving ß-blockers upon discharge; however, home and in-hospital ß-blockers reduced the likelihood of being discharged without a ß-blocker. Of the 129 patients not receiving ß-blockers prehospitalization, 23 (17.8%) were discharged with a new prescription for a ß-blocker. CONCLUSIONS: Nearly one-third of patients with compelling indications for ß-blockers were not prescribed the therapy at discharge.

Comparison of Plasma-Lyte A and Sodium Chloride 0.9% for Fluid Resuscitation of Patients With Diabetic Ketoacidosis.

Purpose: The aim of this study was to compare Plasma-Lyte A (PL) and sodium chloride 0.9% (NS) in regard to time to resolution of diabetic ketoacidosis (DKA) when one fluid was used predominantly over the other for resuscitation. Methods: We performed a retrospective analysis of the records of patients treated for DKA at a large, academic medical center between July 1, 2013, and July 1, 2015. Patients were placed into the PL or NS group based on the predominant fluid they received during fluid resuscitation. Serum biochemistry variables were categorized as follows: initial, 2 to 4 hours, 4 to 6 hours, 6 to 12 hours, and 12 to 24 hours. The primary outcome was mean time to resolution of DKA. Results: Eighty-four patients were included in the study. The primary outcome of mean time to resolution of DKA was similar between the PL (19.74 hours) and NS (18.05 hours) groups (P = .5080). Patients treated with PL had a significantly greater rise in pH within the 4- to 6-hour and 6- to 12-hour periods. The chloride level was significantly higher and the anion gap was significantly lower for the NS group in the 6- to 12-hour period. Conclusion: These data suggest that the use of PL for fluid resuscitation in DKA may confer certain advantages over NS.

Ceftolozane-Tazobactam Pharmacokinetics in a Critically Ill Patient on Continuous Venovenous Hemofiltration.

Extended-infusion ceftolozane-tazobactam treatment at 1.5 g every 8 h was used to treat multidrug-resistant Pseudomonas aeruginosa in a critically ill patient on continuous venovenous hemofiltration. Serum drug concentrations were measured at 1, 4, 5, 6, and 8 h after the start of infusion. Prefilter levels of ceftolozane produced a maximum concentration of drug (Cmax) of 38.57 µg/ml, concentration at the end of the dosing interval (Cmin) of 31.63 µg/ml, time to Cmax (Tmax) of 4 h, area under the concentration-time curve from 0 to 8 h (AUC0-8) of 284.38 µg · h/ml, and a half-life (t1/2) of 30.7 h. The concentrations were eight times the susceptibility breakpoint for the entire dosing interval.

Association of blood pressure with sodium-related knowledge and behaviors in adults with hypertension.

OBJECTIVES To describe sodium-related knowledge and self-reported behaviors in adults with hypertension and assess the association between knowledge and behaviors and blood pressure levels in this population. METHODS Using convenience sampling of patients with hypertension, an oral cross-sectional survey was administered by student pharmacists in 45 community pharmacies in Alabama and Florida in May to July 2012. After survey questions were administered, patients' blood pressures were measured. Data were tested for significance at alpha < 0.05 using bivariate analyses of independent and dependent variables (systolic/diastolic blood pressure [SBP/DBP]) and parallel linear regression of significant independent variables. RESULTS The majority of the 664 patients surveyed were women (59.3%) and white (75.2%). Most resided in urban areas (81.5%). The mean SBP/DBP was 133.3 (SD = 15.7)/81.7 (SD = 9.1) mg Hg. Most participants recognized the relationship between salt intake and high blood pressure (91.1%) and stroke (78.0%). A small percentage of patients reported that they always look for sodium content on food products (15.0%) and always buy low-sodium products (10.6%). Patients with lower knowledge scores (B = -0.01, P < 0.001) and those who were advised to cut down on salt (B = 0.02, P = 0.037) had higher SBP levels when controlled for gender, race, and awareness of their blood pressure goals. In regression analysis, lower knowledge scores were associated with increased DBP levels (B = -0.52, P = 0.014) when controlled for gender and race. CONCLUSION Many patients were not aware of salt in processed food and did not always look for sodium content on nutritional labels. Pharmacists should address dietary salt when interacting with patients with hypertension.

Acute Severe Hyponatremia Induced by a Duloxetine Overdose in an Elderly Woman.

We report a case of acute severe hyponatremia within 24 hours after a duloxetine overdose. An 82-year-old woman presented to the ED after ingesting duloxetine and diltiazem. She became hemodynamically unstable due to the diltiazem overdose and was appropriately resuscitated. During hospitalization she experienced hyponatremia consistent with syndrome of inappropriate antidiuretic hormone (SIADH). Based on the observations we concluded there was a probable relationship between the hyponatremia and the duloxetine overdose. Clinicians should monitor patients' electrolytes for acute disturbances after an overdose of duloxetine.

Alcohol use behaviors among pharmacy students.

OBJECTIVE: To identify reasons for drinking, determine the patterns of alcohol abuse, and explore relationships between drinking motives and alcohol abuse patterns in pharmacy students. METHODS: A cross-sectional anonymous, voluntary, self-administered paper survey instrument was administered to first-year (P1) through third-year (P3) pharmacy students as part of a professional seminar. RESULTS: Survey instruments were completed by 349 pharmacy students (95.9% cooperation rate). Using the Alcohol Use Disorders Identification Test criteria, 23.2% of students reported hazardous or harmful use and 67.2% of students reported consuming alcohol at hazardous levels during the past year. Students who were male (37.0%), single (25.3%), and attended the main campus (26.2%) were more likely than their counterparts to report hazardous or harmful alcohol use. Pharmacy students reported social motives as the most common reason for drinking; however, coping and enhancement motives were more predictive of harmful or hazardous alcohol use. CONCLUSION: Approximately 1 in 4 pharmacy students (23%) reported hazardous or harmful alcohol use. Education about the dangers of alcohol abuse and intervention programs from colleges and schools of pharmacy are recommended to help address this issue.