Sorption, plant uptake and metabolism of benzodiazepines.

Reuse of treated wastewater for irrigation of crops is growing in arid and semi-arid regions, whilst increasing amounts of biosolids are being applied to fields to improve agricultural outputs. Due to incomplete removal in the wastewater treatment processes, pharmaceuticals present in treated wastewater and biosolids can contaminate soil systems. Benzodiazepines are a widely used class of pharmaceuticals that are released following wastewater treatment. Benzodiazepines are represented by a class of compounds with a range of physicochemical properties and this study was therefore designed to evaluate the influence of soil properties on the sorption behaviour and subsequent uptake of seven benzodiazepines (chlordiazepoxide, clonazepam, diazepam, flurazepam, oxazepam, temazepam and triazolam) in two plant species. The sorption and desorption behaviour of benzodiazepines was strongly influenced by soil type and hydrophobicity of the chemical. The partitioning behaviour of these chemicals in soil was a key controller of the uptake and accumulation of benzodiazepines by radish (Raphanus sativus) and silverbeet (Beta vulgaris). Benzodiazepines such as oxazepam that were neutral, had low sorption coefficients (Kd) or had pH-adjusted log octanol-water partition coefficients (log Dow, pH6.3) values close to 2 had the greatest extent of uptake. Conversely, benzodiazepines such as flurazepam that had an ionised functional groups and greater Kd values had comparatively limited accumulation in the selected plant species. Results also revealed active in-plant metabolism of benzodiazepines, potentially analogous to the known metabolic transformation pathway of benzodiazepines in humans. Along with this observed biological transformation of benzodiazepines in exposed plants, previously work has established the widespread presence of the plant signalling molecule γ-amino butyric acid (GABA), which is specifically modulated by benzodiazepines in humans. This highlights the need for further assessment of the potential for biological activity of benzodiazepines following their plant uptake.

An alternative approach for assessment of liquid chromatography-mass spectrometry matrix effects using auto-sampler programmed co-injection.

We report the use of auto-sampler programmable functions to co-inject analyte standard solution and matrix extract to assess ion enhancement and suppression (matrix effects) in LC-MS. This is effectively an automated post-extraction addition (APEA) procedure, emulating the manual post-extraction addition (PEA) approach widely adopted for assessment of matrix effects. To verify that APEA was comparable to the conventional PEA approach, matrix effects were determined using both methods for a selection of 31 illicit and pharmaceutical drugs in 10 different human urine extracts. Matrix effects measured using APEA were statistically indistinguishable from manual PEA methodology for 27 of the 31 drugs. Of the four drugs that showed significant differences using the two methods, three differed by less than 2 %, which is within the expected accuracy limits required for matrix effect determinations. The remaining analyte, trimeprazine, was found to degrade in the spiked PEA matrix extract, accounting for the difference between matrix effects measured by the PEA and APEA approaches. APEA enables a single matrix extract to be assessed at multiple analyte concentrations, resulting in a considerable reduction in sample preparation time. In addition, APEA can reduce the quantity of analyte-free sample matrix required for matrix effect assessment, which is an important consideration in certain analytical and bioanalytical fields. This work shows that APEA may be considered as an acceptable alternative to PEA for the assessment of matrix effects in LC-MS method validation and may be applicable to a variety of matrices such as environmental samples.

Evaluation of Speech Perception via the Use of Hearing Loops and Telecoils.

A cross-sectional, experimental, and randomized repeated-measures design study was used to examine the objective and subjective value of telecoil and hearing loop systems. Word recognition and speech perception were tested in 12 older adult hearing aid users using the telecoil and microphone inputs in quiet and noise conditions. Participants were asked to subjectively rate cognitive listening effort and self-confidence for each condition. Significant improvement in speech perception with the telecoil over microphone input in both quiet and noise was found along with significantly less reported cognitive listening effort and high self-confidence. The use of telecoils with hearing aids should be recommended for older adults with hearing loss.

Council on Accreditation of Nurse Anesthesia Educational Programs adopts standards for the Practice Doctorate and Post-graduate CRNA Fellowships.

The Council on Accreditation of Nurse Anesthesia Educational Programs appointed a Standards Revision Task Force to develop new accreditation standards. After 3 years of research and development (2011-2013) by the task force, the Council approved the first entry-level Practice Doctorate Standards and the first voluntary Post-graduate CRNA Fellowship Standards in January 2014. This defining moment in accreditation history marks a transition in the educational preparation of entry-level nurse anesthetists and provides opportunities for learning in a variety of post-graduate fellowships for Certified Registered Nurse Anesthetists.

Behaviour of fullerenes (C60) in the terrestrial environment: potential release from biosolids-amended soils.

Owing of their wide-range of commercial applications, fullerene (C60) nanoparticles, are likely to reach environments through the application of treated sludge (biosolids) from wastewater treatment plants to soils. We examined the release behaviour of C60 from contaminated biosolids added to soils with varying physicochemical characteristics. Incubation studies were carried out in the dark for up to 24 weeks, by adding biosolids spiked (1.5mg/kg) with three forms of C60 (suspended in water, in humic acid, and precipitated/particulate) to six contrasting soils. Leaching of different biosolids+soil systems showed that only small fractions of C60 (<5% of applied amount) were released, depending on incubation time and soil properties (particularly dissolved organic carbon content). Release of C60 from unamended soils was greater (at least twice as much) than from biosolids-amended soils. The form of C60 used to spike the biosolids had no significant effect on the release of C60 from the different systems. Contact time of C60 in these systems only slightly increased the apparent release up to 8 weeks, followed by a decrease to 24 weeks. Mass balance analysis at the completion of the experiment revealed that 20-60% of the initial C60 applied could not be accounted for in these systems; the reasons for this are discussed.

Marked changes in herbicide sorption-desorption upon ageing of biochars in soil.

We studied the sorption-desorption behaviour of two herbicides (diuron and artrazine) in a soil rich in Fe and Al oxides (Ferrosol), either amended freshly with two different types of biochars or that contained biochars aged under field conditions. Standard batch sorption-desorption experiments were conducted on soil samples freshly amended with two biochars, (namely, poultry litter - PL and paper mill - PM sludge) as well on those collected from field 32 months after biochar application. Soils that were freshly amended with biochars @ 10 t ha(-1) showed a two (PM) to five (PL) fold increase in sorption of herbicides as compared with that in the unamended soil. For example, the fresh amendments with PL biochar at 10 t ha(-1) led to a highly significant (P<0.001) increase in the Freundlich sorption coefficient (K(f)) of atrazine; i.e. 20.71 (n=0.40) as compared with 4.02 (n=0.70) for the control soil. Sorption was reversible in the unamended soil but sorption-desorption hysteresis was prominent in the soil amended with fresh biochars. In contrast, the soil containing aged biochars (at 10 t ha(-1)) exhibited sorption-desorption properties that were statistically similar to that of the control soil, especially for atrazine. Ageing of biochars in the soil over a 32 months period reduced the sorption capacity by 47% (PM) to 68% (PL) for diuron. These findings may have implications for herbicide efficacy in biochar amended soils.

The perceived influence of financial risk factors on the viability of nurse anesthesia educational programs.

Monetary cutbacks have occurred in the healthcare industry with increasing incidence since the mid-1980s. Attempts at self-preservation through cost-constraint have been instituted by hospitals, Medicare and Medicaid, and private insurance companies. Curtailment of expenditures, as well as reestablishing profit, has taken many forms. These include managed care, mergers, changing profit status, and aggressive competition. The purpose of this study was to evaluate whether directors of nurse anesthesia programs (NAPs) perceived these items as being detrimental to their NAPs. Data were gathered by descriptive survey design by completing a survey tool. Findings identified directors perceived NAPs at moderate to high risk for closure because of the financial constraints hospitals are experiencing as a result of healthcare reimbursement cutbacks. We found it interesting that many directors were either unaware or considered the hospitals' financial burdens as not impacting their NAP. However, directors who had taken courses or seminars with a focus on issues affecting the financing and reimbursement of healthcare institutions perceived significantly greater risk than those who did not. Potential learning opportunities and strategies to ameliorate risk were identified. Additional education may provide the knowledge and insight to find alternatives to risk, develop strategies, and promote more successful and stable nurse anesthesia educational programs.

Factors that influenced six nurse anesthesia programs to close.

The well-being of the profession of nurse anesthesia requires sound education programs to educate the cadre of providers in the specialty practice of anesthesia nursing to meet societal needs. Many factors in the environment can have an impact on a program's ability to achieve this goal. Where factors are adverse, it can force a program to close. Closure of education programs should be a matter of concern to the entire nurse anesthesia community. However, complex factors can only be understood when information about their nature and characteristics is current. Making predictions about how a system may respond based on decade-old data is neither an efficient nor effective method to develop strategy-based solutions. This study identified factors that influenced decisions to close six nurse anesthesia education programs. Armed with this information, other programs can better prepare to counter the negative influences that could lead to their closing.

AANA Journal Course: update for nurse anesthetists--management of malignant ventricular tachyarrhythmias: the role of drug therapy and surgical intervention in sudden cardiac death survivors.

The use of implantable cardioverter-defibrillators (ICDs) to treat patients with ventricular tachyarrhythmias and sudden cardiac death (SCD) has increased over the last decade. Once applied as therapy of last resort, new surgical techniques and improved technology have made the procedure relatively noninvasive. As a result, it is becoming increasingly more common for patients to undergo insertion of this life-saving device in nonoperating room locations. Because patients who require insertion of ICDs often have significant underlying cardiac disease, developing a plan of anesthesia management tailored to meet their needs and predispositions may be a challenge. This Journal Course reviews, from an historical as well as contemporary perspective, the medical and surgical management of patients with ventricular tachyarrhythmias at risk to sustain SCD. A case presentation format is utilized to illustrate an example of an anesthetic plan of care for a patient who underwent insertion of an ICD. Additional information is presented regarding the impact of the ICD on quality of life and overall healthcare costs. As our healthcare system continues to change and evolve, when treatment options are considered, quality of life and cost issues are becoming increasingly more important.

Comparison of ondansetron, metoclopramide, and placebo in the prevention of postoperative emesis in children undergoing ophthalmic surgery.

A common and distressing adverse effect following general anesthesia is nausea and vomiting. Pediatric ophthalmic surgery is associated with a high (50%-80%) incidence of postoperative emesis. Vomiting postoperatively may cause a prolonged hospital stay, and if it is persistent, may lead to unanticipated hospital admission after ambulatory surgery. The purpose of the present study was to compare the effectiveness of prophylactic antiemetic treatment with ondansetron, metoclopramide, and placebo in a study population of pediatric patients scheduled to undergo ophthalmic surgery. One hundred and one patients were included in this double-blinded study. The incidence of emesis and adverse effects were observed in the postanesthesia care unit and documented for 24 hours postoperatively. Analysis of variance showed that ondansetron significantly decreased (P = .05) the incidence of emesis in the postanesthesia care unit and during the first 24 hours postoperatively (P = .049). Additionally, parents of children in the ondansetron group reported a high degree (94%) of satisfaction with the experience.

Anesthesia providers, patient outcomes, and costs: a critique.

The June 1996 article in Anesthesia and Analgesia by Abenstein and Warner entitled "Anesthesia Providers, Patient Outcomes, and Costs" presents important information about anesthesia services, but it contains a number of errors and questionable interpretations that could lead to inappropriate programs and policies. Among the most important points of fact we clarify in our paper are: 1. Three organizations that accredit, certify, and govern nurse anesthetists are organized in similar fashion to three comparable bodies governing anesthesiologists. There is no justification for the implication that the AANA somehow controls the accreditation and certification of CRNAs. 2. The conclusion that anesthesiologistled care teams are the preferred model for all anesthesia services and settings because of improved patient outcomes is overly simplistic and is not borne out in the literature. 3. The attribution of reduced mortality from anesthesia over the past 40 years to the increase in numbers of anesthesiologists is not justified. Many other factors, including new anesthetic agents and improved patient monitoring, also are important. 4. The use of a hypothetical example related to Medicare reimbursement in New York to justify the implication that CRNA-delivered services are more costly than anesthesiologist-delivered services is misleading and not borne out in the literature. We hope that planners and policy makers will read the article by Abenstein and Warner with extreme caution. Taking some of their statements and conclusions seriously could lead to policies and programs that are not focused in science.

Postoperative nausea and vomiting after strabismus surgery: mechanisms, treatment, and implications for practice.

The occurrence of postoperative nausea and vomiting in children after strabismus surgery has historically been a challenging aspect of anesthetic management. This article provides an overview of the cause, physiology, and mechanisms of post surgical vomiting in this patient population. Current pharmacological treatment modalities and implications for future practice are examined.

Anesthetic management for the implantable cardioverter-defibrillator.

The use of implantable cardioverter-defbrillators to treat ventricular tachyarrhythmias has increased over the last 15 years. This article presents a description of third- and fourth-generation implantable cardioverter-defibrillators (ICDs), including information concerning their use, patient selection criteria, surgical implantation techniques, and anesthetic implications. A brief history of the development of the ICD is discussed. Indications, contraindications and complications are examined.

Discharge time in patients who receive fentanyl or alfentanil for general anesthesia.

Forty ASA I and II patients undergoing elective termination of pregnancy were studied. Patients were randomly selected to receive fentanyl or alfentanil. Patients received 1 to 2 mg midazolam, 2.0 to 2.5 mg/kg propofol, and 10 to 20 micrograms/kg alfentanil or 1 to 2 micrograms/kg fentanyl for induction and maintenance of anesthesia. In addition all patients were administered 70% N2O and 30% O2. The time from admission to the post anesthesia recovery unit until discharged home was defined as the discharge time. These times were compared using the student's t test to determine if there was a significant difference (P < .05) between the mean discharge time of the two groups. In addition, each patient's total postanesthesia recovery scores were evaluated on admission, at 15 minutes, and at discharge from the post anesthesia recovery unit. These data were analyzed using the Mann-Whitney U test to determine if there was a significant difference in the mean rate of recovery in each area observed. The data revealed no statistically significant difference between the mean discharge times of the two groups or in the total post anesthesia recovery unit recovery scores.

Outcome assessment in education programs.

This article describes the move toward outcome assessment as a tool to measure student achievement and overall program effectiveness. Methods are presented by which on-site accreditation reviewers can determine if nurse anesthesia faculty perform effective assessments and utilize the results of their findings to plan for improvement. Emphasis is placed on methods by which data from multiple sources are collected and analyzed by the faculty to enhance student learning.