Hypoactive Delirium: Differential Diagnosis, Evaluation, and Treatment.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2024;26(1):23f03602. Author affiliations are listed at the end of this article.

Good Functional Outcomes and Low Infection Rates in Total Hip Arthroplasty in HIV-Positive Patients, Provided There Is Strict Compliance With Highly Active Antiretroviral Therapy.

BACKGROUND: Patients with HIV are more likely to require a total hip arthroplasty (THA) because of an increase in life expectancy and complications with HIV. The purpose of this study is to describe the mid-term outcomes of THA in HIV-positive patients and risk factors for postoperative infections and poor outcomes. METHODS: This is a single-center retrospective review of nonhemophiliac HIV-positive patients who underwent THA. We reviewed the short- and mid-term readmission and complication rates. RESULTS: Eighty-seven patients underwent 102 THAs. The average age was 58 years (24-73 years). The average body mass index was 31.6 (18-55). The average CD4+ count was 569 cells per cubic millimeter (mm3) (51-1480), and the mean viral load was <40 copies/mL (undetectable-380 000). The mean follow-up time was 6.7 years (24 months- 8.3 years). Four patients had postoperative complications within 30 days. Seven patients had postoperative complications after 30 days; 5 of which had septic loosening of implants and had either not been initiated on or were noncompliant with their highly active antiretroviral therapy. The average postoperative Harris Hip Score was 81 (41-100) and Oxford Hip Score was 43.43 (34-48). There was no correlation the between CD4+ count and viral load with complications. CONCLUSION: Low rate of complications and revision is achievable in the HIV-positive, nonhemophilic arthroplasty population contrary to published literature. An important factor ensuring good long-term outcomes in HIV-positive patients undergoing THA was the initiation of highly active antiretroviral therapy before the procedure and ensuring patient compliance with therapy after joint arthroplasty.

Relational Cities Disrupted: Reflections on the Particular Geographies of COVID-19 For Small But Global Urbanisation in Dublin, Ireland, and Luxembourg City, Luxembourg.

This paper looks at the particular geographies associated with the COVID-19 outbreak through the lens of cities that are products of relational urbanisation. This includes small but highly globalised cities, such as financial centres or hot spots of politics and diplomacy, which are usually situated between different political, economic or cultural systems and their boundaries. These cities experienced strong growth due to internationalisation and a dedicated politics of extraversion. Our argument is that such places are unusually affected by the current lock-down, illustrated by two empirical cases, the cities of Dublin, Ireland, and Luxembourg City, Luxembourg. Both have experienced striking growth rates recently, but now suffer from disruption. Their development trajectories remain unclear, since a return to the 'old normal' seems unlikely, and the emergent 'new normal' calls for adaptation towards more state involvement in areas hitherto governed by the market. The paper addresses possible alternative geographies for both cases.

Use of Fat-Suppressed T2-Weighted MRI Images to Reduce the Magic Angle Effect in Peroneal Tendons.

INTRODUCTION: Peroneal tendon disorders pose a diagnostic conundrum to the clinician. Magnetic resonance imaging (MRI) is widely used to assess tendon pathology. A recognized artifact of MRI, the magic angle effect (MAE), can lead to spurious results and inappropriate management. The aim of this study is to assess whether T2 fat-suppressed sequences (T2FSs) reduce the frequency of MAE compared with proton density fat-suppressed (PDFS) images. METHODS: MRI scans of 18 patients were prospectively assessed for MAE. The peroneal tendons were assessed at 5 defined levels on PDFS and T2FS images. The frequency of MAE in the peroneal tendons were compared between the 2 scan sequences. RESULTS: In the peroneus brevis tendon, 17/72 levels, on PDFS scans, showed MAE compared with 2/72 levels on the T2FS scans, demonstrating a reduction in the MAE by 85% (P = .0003). In the peroneus longus tendon 14/72 levels, on PDFS scans, demonstrated MAE compared with 4/72 on T2FSs, demonstrating a reduction of 71% (P = .02). CONCLUSION: The inclusion of T2-weighted sequences is useful in MRI scanning for peroneal tendons to mitigate the MAE artifact, avoid potential misdiagnosis, and guide subsequent management of peroneal tendon disorders. Levels of Evidence: Level IV: Case series.

No Denying It: Medicinal Chemistry Training Is in Big Trouble.

There has been little consensus between the pharmaceutical industry and academic communities concerning the best approach to train medicinal chemists for drug discovery. For decades the pharmaceutical industry has shown preference for synthetic organic graduates over candidates with degrees from medicinal chemistry programs on the assumption that medicinal chemistry expertise will be acquired on the job. However, ongoing changes to pharmaceutical drug discovery organizations and practices threaten to undermine this training model. There is a compelling argument to be made for establishment of a strong industry-academic partnership to train new candidates with sophisticated knowledge of contemporary drug design concepts and techniques to ensure that the future needs of both industry and academic drug discovery research can be served.

The unaccountable risks of LIBOR.

One of the on-going consequences of recent financial crises seems to be that the conventional 'anchor' measures of global finance (such as the US dollar, treasury bonds and AAA rated securities) are no longer playing the anchoring role once believed of them. LIBOR now needs to be added to this list and not just because it has been tarnished by illegal practices, but because it is looking increasingly surpassed by financial market practices. LIBOR was believed to provide a risk-free rate of interest, but has been revealed to be risk-laden. Moreover, LIBOR is a measure of the costs of borrowing, whilst market concern is increasingly with measures of interest rate volatility. This paper looks at why, in the context of crisis, financial market focus on interest rates is turning towards other benchmarks, notably the overnight indexed swap (OIS) market, and what this shift might be telling us about the anchoring requirements of global financial markets.

Cross-sectional study of alteration of phantom limb pain with visceral stimulation in military personnel with amputation.

While phantom limb pain is a well-recognized phenomenon, clinical experience has suggested that the augmentation of phantom limb pain with visceral stimulation is an issue for many military personnel with amputation (visceral stimulation being the sensation of the bowel or bladder either filling or evacuating). However, the prevalence of this phenomenon is not known. The aim of this study was to investigate the prevalence of the alteration in phantom limb pain and the effect that visceral stimulation has on phantom limb pain intensity. A cross-sectional study of 75 military personnel who have lost one or both lower limbs completed a questionnaire to assess the prevalence of the alteration of phantom limb pain with visceral stimulation. Included in the questionnaire was a pain visual analog scale (VAS) graded from 0 to 10. Patients recorded the presence and intensity of phantom limb pain. They also recorded whether and how this pain altered with a need to micturate or micturition, and/or a need to defecate or defecation, again using a pain VAS. Time since amputation, level of amputation, and medications were also recorded. Patients reported a phantom limb pain prevalence of 85% with a mean VAS of 3.6. In all, 56% of patients reported a change in the severity of phantom limb pain with visceral stimuli. The mean increase in VAS for visceral stimulation was 2.5 +/- 1.6 for bladder stimulation and 2.9 +/- 2.0 for bowel stimulation. Of the patients questioned, 65% reported an improvement in symptoms over time. VAS scores were highest in the subgroup less than 6 mo postamputation. An increase in phantom limb pain with visceral stimulation is a common problem for military personnel with amputation.

The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom.

BACKGROUND: Musculoskeletal symptoms are common reasons for patients seeking medical attention. Basic competency in musculoskeletal medicine is therefore essential for all clinicians. To our knowledge, this is the first assessment of the competency in musculoskeletal medicine of medical students in the United Kingdom. METHODS: Medical students were enrolled after passing final university examinations and being awarded degrees of Bachelor of Medicine, Bachelor of Surgery (MBBS) or Medicinae Baccalaureus, Baccalaureus Chirurgiae (MBChB) in 2013 and were assessed with use of the Freedman and Bernstein musculoskeletal cognitive examination tool. RESULTS: Two hundred and thirty students were recruited, of whom 210 were suitable for inclusion. Only 21% (forty-four students) passed the assessment. Mandatory exposure to musculoskeletal medicine during medical school consisted of orthopaedics for 100% of participants for a mean duration of 2.65 weeks, rheumatology for 96% of participants for a mean duration of 2.5 weeks, and sports medicine for 1% of participants for a mean duration of two weeks. There was a significant difference (p = 0.002) in scores between those with career interests in musculoskeletal specialties (69.3%) and the rest of the cohort (54.9%). There was also a significant difference (p = 0.001) in scores between participants with career interests in general practice (42%) and the rest of the cohort (56%). Only 40% of participants considered themselves competent in musculoskeletal medicine. Fifty-five percent thought that musculoskeletal conditions would be an important component of their future practice. CONCLUSIONS: Our findings suggest that medical schools may be currently failing to ensure that medical students have a basic competence in musculoskeletal medicine. Further investigation is warranted to fully assess the current training provided by U.K. medical schools in musculoskeletal medicine, and appropriate steps must be taken to improve the quantity and quality of training in musculoskeletal medicine in the United Kingdom.

The design and synthesis of human branched-chain amino acid aminotransferase inhibitors for treatment of neurodegenerative diseases.

The inhibition of the cytosolic isoenzyme BCAT that is expressed specifically in neuronal tissue is likely to be useful for the treatment of neurodegenerative and other neurological disorders where glutamatergic mechanisms are implicated. Compound 2 exhibited an IC50 of 0.8 microM in the hBCATc assays; it is an active and selective inhibitor. Inhibitor 2 also blocked calcium influx into neuronal cells following inhibition of glutamate uptake, and demonstrated neuroprotective efficacy in vivo. SAR, pharmacology, and the crystal structure of hBCATc with inhibitor 2 are described.

Multivariate analysis of paired watershed data to evaluate agricultural best management practice effects on stream water phosphorus.

Quantification of the effects of management programs on water quality is critical to agencies responsible for water resource protection. This research documents reductions in stream water phosphorus (P) loads resulting from agricultural best management practices (BMPs) implemented as part of an effort to control eutrophication of Cannonsville Reservoir, a drinking water supply for New York City. Dairy farms in the upstate New York reservoir basin were the target of BMPs designed to reduce P losses. A paired watershed study was established on one of these farms in 1993 to evaluate changes in P loading attributable to implementation of BMPs that included manure management, rotational grazing, and improved infrastructure. Intensive stream water monitoring provided data to calculate P loads from the 160-ha farm watershed for all runoff events during a two-year pre-treatment period and a four-year post-treatment period. Statistical control for inter-annual climatic variability was provided by matched P loads from a nearby 86-ha forested watershed, and by several event flow variables measured at the farm. A sophisticated multivariate analysis of covariance (ANCOVA) provided estimates of both seasonal and overall load reductions. Statistical power and the minimum detectable treatment effect (MDTE) were also calculated. The results demonstrated overall event load reductions of 43% for total dissolved phosphorus (TDP) and 29% for particulate phosphorus (PP). Changes in farm management practices and physical infrastructure clearly produced decreases in event P losses measurable at the small watershed scale.