Utility of a pharmacist-managed Anticoagulation Program in patients with congenital heart disease.

BACKGROUND: Warfarin remains the preferred anticoagulant for many patients with CHD. The complexity of management led our centre to shift from a nurse-physician-managed model with many providers to a pharmacist-managed model with a centralized anticoagulation team. We aim to describe the patient cohort managed by our Anticoagulation Program and evaluate the impact of implementation of this consistent, pharmacist-managed model on time in therapeutic range, an evidence-based marker for clinical outcomes. METHODS: A single-centre retrospective cohort study was conducted to evaluate the impact of the transition to a pharmacist-managed model to improve anticoagulation management at a tertiary pediatric heart centre. The percent time in therapeutic range for a cohort managed by both models was compared using a paired t-test. Patient characteristics and time in therapeutic range of the program were also described. RESULTS: After implementing the pharmacist-managed model, the time in therapeutic range for a cohort of 58 patients increased from 65.7 to 80.2% (p < .001), and our Anticoagulation Program consistently maintained this improvement from 2013 to 2022. The cohort of patients managed by the Anticoagulation Program in 2022 included 119 patients with a median age of 24 years (range 19 months-69 years) with the most common indication for warfarin being mechanical valve replacement (n = 81, 68%). CONCLUSIONS: Through a practice change incorporating a collaborative, centralized, pharmacist-managed model, this cohort of CHD patients on warfarin had a fifteen percent increase in time in therapeutic range, which was sustained for nine years.

Hierarchical status is rapidly assessed from behaviourally dominant faces.

Recognition of social hierarchy is a key feature that helps us navigate through our complex social environment. Neuroimaging studies have identified brain structures involved in the processing of hierarchical stimuli, but the precise temporal dynamics of brain activity associated with such processing remains largely unknown. In this investigation, we used event-related potentials (ERPs) to examine the effect of social hierarchy on the neural responses elicited by dominant and nondominant faces. Participants played a game where they were led to believe that they were middle-rank players, responding alongside other alleged players, whom they perceived as higher or lower-ranking. ERPs were examined in response to dominant and nondominant faces, and low-resolution electromagnetic tomography (LORETA) was used to identify the implicated brain areas. The results revealed that the amplitude of the N170 component was enhanced for faces of dominant individuals, showing that hierarchy influences the early stages of face processing. A later component, the late positive potential (LPP) appearing between 350-700 ms, also was enhanced for faces of higher-ranking players. Source localisation suggested that the early modulation was due to an enhanced response in limbic regions. These findings provide electrophysiological evidence for enhanced early visual processing of socially dominant faces.

A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty.

BACKGROUND: Ketamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA). METHODS: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses. RESULTS: High-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92). CONCLUSION: High-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly.

The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis.

BACKGROUND: Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids. RESULTS: Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA. CONCLUSION: Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis.

BACKGROUND: Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS: Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION: Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis.

BACKGROUND: Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks. RESULTS: Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective. CONCLUSION: Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.

The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis.

BACKGROUND: Regional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks. RESULTS: An initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption. CONCLUSION: Local periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.

Effects of emotional cues on novel word learning in typically developing children in relation to broader autism traits.

Emotion can influence various cognitive processes. Communication with children often involves exaggerated emotional expressions and emotive language. Children with autism spectrum disorder often show a reduced tendency to attend to emotional information. Typically developing children aged 7 to 9 years who varied in their level of autism-like traits learned the nonsense word names of nine novel toys, which were presented with either happy, fearful, or neutral emotional cues. Emotional cues had no influence on word recognition or recall performance. Eye-tracking data showed differences in visual attention depending on the type of emotional cues and level of autism-like traits. The findings suggest that the influence of emotion on attention during word learning differs according to whether the children have lower or higher levels of autism-like traits, but this influence does not affect word learning outcomes.

Children overclaim more knowledge than adults do, but for different reasons.

Overclaiming is the phenomenon whereby people claim more knowledge of a topic than they actually have. In adults, this behavior is related to the extent to which they consider themselves an expert on that topic and may be related to impression management. We investigated the emergence of this phenomenon by developing a child-friendly overclaiming questionnaire (OCQ)-the Child-OCQ. We measured the tendency of children (5-10 years of age old; N = 94) to claim knowledge of items that did not exist for a variety of topics (places, characters, animals, food, and musical instruments). We also examined the relationship between children's overclaiming of knowledge and their self-perceived liking of, and expertise in, the topics. To validate our scale, an adult sample (N = 51) completed both the Child-OCQ and a standardized adult OCQ, the OCQ-150, showing similar overclaiming patterns on both measures. Although overclaiming behaviors decreased throughout childhood, even children as old as 10 years were not adult-like and were more likely to overclaim knowledge than adults. In addition, we did not find strong evidence that children's perceived expertise on a topic influenced their tendency to overclaim knowledge, suggesting that the mechanisms behind the overclaiming phenomenon are different in children and do not reflect impression management until later during adolescence or adulthood.

Winners and losers: Recognition of spontaneous emotional expressions increases across childhood.

Research using posed emotional expressions is problematic because they lack ecological validity. Adults' recognition of spontaneous real-world expressions may require the inclusion of postural information. Whether posture improves children's recognition of real-world expressions was unknown. Younger children (n = 30; 5- to 7-year-olds), older children (n = 30; 8- to 10-year-olds), and adults (n = 30) judged whether tennis players had won or lost a point. Images showed one of three cue types: Head-only, Body-only, or Head-Body expressions. Recognition of expressions improved with age; older children and adults performed better than younger children. In addition, recognition of Body-only and Head-Body cues was better than Head-only cues for all ages. Spontaneous expression recognition improved throughout childhood and with the inclusion of postural information.

Idea Formulation for Spoken Language Production: The Interface of Cognition and Language.

BACKGROUND: Language and communication are fundamental to the human experience, and, traditionally, spoken language is studied as an isolated skill. However, before propositional language (i.e., spontaneous, voluntary, novel speech) can be produced, propositional content or 'ideas' must be formulated. OBJECTIVE: This review highlights the role of broader cognitive processes, particularly 'executive attention', in the formulation of propositional content (i.e., 'ideas') for propositional language production. CONCLUSIONS: Several key lines of evidence converge to suggest that the formulation of ideas for propositional language production draws on executive attentional processes. Larger-scale clinical research has demonstrated a link between attentional processes and language, while detailed case studies of neurological patients have elucidated specific idea formulation mechanisms relating to the generation, selection and sequencing of ideas for expression. Furthermore, executive attentional processes have been implicated in the generation of ideas for propositional language production. Finally, neuroimaging studies suggest that a widely distributed network of brain regions, including parts of the prefrontal and parietal cortices, supports propositional language production. IMPLICATIONS: Theoretically driven experimental research studies investigating mechanisms involved in the formulation of ideas are lacking. We suggest that novel experimental approaches are needed to define the contribution of executive attentional processes to idea formulation, from which comprehensive models of spoken language production can be developed. Clinically, propositional language impairments should be considered in the context of broader executive attentional deficits.

Interactive situations reveal more about children's emotional knowledge.

Research examining children's emotion judgments has generally used nonsocial tasks that do not resemble children's daily experiences in judging others' emotions. Here, younger children (4- to 6-year-olds) and older children (7- to 9-year-olds) participated in a socially interactive task where an experimenter opened boxes and made an expression (happy, sad, scared, or disgust) based on the object inside. Children guessed which of four objects (a sticker, a broken toy car, a spider, or toy poop) was in the box. Subsequently, children opened a set of boxes and generated facial expressions for the experimenter. Children also labeled the emotion elicited by the objects and static facial expressions. Children's ability to guess which object caused the experimenter's expression increased with age but did not predict their ability to generate a recognizable expression. Children's demonstration of emotion knowledge also varied across tasks, suggesting that when emotion judgment tasks more closely mimic their daily experiences, children demonstrate broader emotion knowledge.

Cross-modal emotion recognition and autism-like traits in typically developing children.

The ability to explicitly recognize emotions develops gradually throughout childhood, and children usually have greater difficulty in recognizing emotions from the voice than from the face. However, little is known about how children integrate vocal and facial cues to recognize an emotion, particularly during mid to late childhood. Furthermore, children with an autism spectrum disorder often show a reduced ability to recognize emotions, especially when integrating emotion from multiple modalities. The current preliminary study explored the ability of typically developing children aged 7-9 years to match emotional tones of voice to facial expressions and whether this ability varies according to the level of autism-like traits. Overall, children were the least accurate when matching happy and fearful voices to faces, commonly pairing happy voices with angry faces and fearful voices with sad faces. However, the level of autism-like traits was not associated with matching accuracy. These results suggest that 7- to 9-year-old children have difficulty in integrating vocal and facial emotional expressions but that differences in cross-modal emotion matching in relation to the broader autism phenotype are not evident in this task for this age group with the current sample.

Outpatient Burn Care: Prevention and Treatment.

Most patients with burn injuries are treated as outpatients. Two key determinants of the need for referral to a burn center are burn depth and percentage of total body surface area involved. All burn injuries are considered trauma, prompting immediate evaluation for concomitant injuries. Initial treatment is directed at stopping the burn process. Superficial (first-degree) burns involve only the epidermal layer and require simple first-aid techniques with over-the-counter pain relievers. Partial-thickness (second-degree) burns are subdivided into two categories: superficial and deep. Superficial partial-thickness burns extend into the dermis, may take up to three weeks to heal, and require advanced dressings to protect the wound and promote a moist environment. Deep partial-thickness burns require immediate referral to a burn surgeon for possible early tangential excision. Full-thickness (third-degree) burns involve the entire dermal layer, and patients with these burns should automatically be referred to a burn center. Prophylactic antibiotics are not indicated for outpatient management and may increase bacterial resistance. People with diabetes mellitus are at increased risk of complications and infection, and early referral to a burn center should be considered. Pruritus, hypertrophic scarring, and permanent hyperpigmentation are long-term complications of partial-thickness burns. Burn injuries are more likely to occur in children and older people. Patient education during primary care visits may be an effective prevention strategy.

Development of emotion recognition in popular music and vocal bursts.

Previous research on the development of emotion recognition in music has focused on classical, rather than popular music. Such research does not consider the impact of lyrics on judgements of emotion in music, impact that may differ throughout development. We had 172 children, adolescents, and adults (7- to 20-year-olds) judge emotions in popular music. In song excerpts, the melody of the music and the lyrics had either congruent valence (e.g. happy lyrics and melody), or incongruent valence (e.g. scared lyrics, happy melody). We also examined participants' judgements of vocal bursts, and whether emotion identification was linked to emotion lexicon. Recognition of emotions in congruent music increased with age. For incongruent music, age was positively associated with judging the emotion in music by the melody. For incongruent music with happy or sad lyrics, younger participants were more likely to answer with the emotion of the lyrics. For scared incongruent music, older adolescents were more likely to answer with the lyrics than older and younger participants. Age groups did not differ on their emotion lexicons, nor recognition of emotion in vocal bursts. Whether children use lyrics or melody to determine the emotion of popular music may depend on the emotion conveyed.

Fcγ receptors and toll-like receptor 9 synergize to drive immune complex-induced dendritic cell maturation.

Previous in vivo studies established that inactivated Francisella tularensis immune complexes (mAb-iFt) are a more protective vaccine against lethal tularemia than iFt alone. Subsequent in vitro studies revealed enhanced DC maturation marker expression with mAb-iFt stimulation. The goal of this study was to determine the mechanism of enhanced DC maturation. Multiparameter analysis of surface marker expression and cytokine secretion demonstrates a requirement for FcγR signaling in enhanced DC maturation. MyD88 was also found to be essential for heightened DC maturation, implicating MyD88-dependent TLRs in DC maturation. Upon further study, we discovered that TLRs 2 & 4 drive cytokine secretion, but surprisingly TLR9 is required for DC maturation marker upregulation. These studies reveal a separation of DC cytokine and maturation marker induction pathways and demonstrate that FcγR-TLR/MyD88 synergy underlies the enhanced dendritic cell maturation in response to the mAb-iFt vaccine.

Sexual Selection, Agonistic Signaling, and the Effect of Beards on Recognition of Men's Anger Displays.

The beard is arguably one of the most obvious signals of masculinity in humans. Almost 150 years ago, Darwin suggested that beards evolved to communicate formidability to other males, but no studies have investigated whether beards enhance recognition of threatening expressions, such as anger. We found that the presence of a beard increased the speed and accuracy with which participants recognized displays of anger but not happiness (Experiment 1, N = 219). This effect was not due to negative evaluations shared by beardedness and anger or to negative stereotypes associated with beardedness, as beards did not facilitate recognition of another negative expression, sadness (Experiment 2, N = 90), and beards increased the rated prosociality of happy faces in addition to the rated masculinity and aggressiveness of angry faces (Experiment 3, N = 445). A computer-based emotion classifier reproduced the influence of beards on emotion recognition (Experiment 4). The results suggest that beards may alter perceived facial structure, facilitating rapid judgments of anger in ways that conform to evolutionary theory.

Mothers are sensitive to men's beards as a potential cue of paternal investment.

Mating strategy theories assert that women's preferences for androgen dependent traits in men are stronger when the costs of reduced paternal investment are lowest. Past research has shown that preferences for facial masculinity are stronger among nulliparous and non-pregnant women than pregnant or parous women. In two studies, we examine patterns in women's preferences for men's facial hair - likely the most visually conspicuous and sexually dimorphic of men's secondary sexual traits - when evaluating men's masculinity, dominance, age, fathering, and attractiveness. Two studies were conducted among heterosexual pregnant women, mothers, non-contractive and contraceptive users. Study 1 used a between-subjects sample (N = 2103) and found that mothers had significantly higher preferences for beards when judging fathering than all other women. Pregnant women and mothers also judged beards as more masculine and older, but less attractive, than non-contractive and contraceptive users. Parous women judged beards higher for age, masculinity and fathering, but lower for attractiveness, than nulliparous women. Irrespective of reproductive status, beards were judged as looking more dominant than clean-shaven faces. Study 2 used a within-subjects design (N = 53) among women surveyed during pregnancy and three months post-partum. Judgments of parenting skills were higher for bearded stimuli during pregnancy among women having their first baby, whereas among parous women parenting skills judgments for bearded stimuli were higher post-partum. Our results suggest that mothers are sensitive to beardedness as a masculine secondary sexual characteristic that may denote parental investment, providing evidence that women's mate preferences could reflect sexual selection for direct benefits.

The influence of subtle facial expressions on children's first impressions of trustworthiness and dominance is not adult-like.

Adults' first impressions of others are influenced by subtle facial expressions; happy faces are perceived as high in trustworthiness, whereas angry faces are rated as low in trustworthiness and high in threat and dominance. Little is known about the influence of emotional expressions on children's first impressions. Here we examined the influence of subtle expressions of happiness, anger, and fear on children's implicit judgments of trustworthiness and dominance with the aim of providing novel insights about both the development of first impressions and whether children are able to utilize emotional expressions when making implicit, rather than explicit, judgments of traits. In the context of a computerized storybook, children (4- to 11-year-olds) and adults selected one of two twins (two images of the same identity displaying different emotional expressions) to help them face a challenge; some challenges required a trustworthy partner, and others required a dominant partner. One twin posed a neutral expression, and the other posed a subtle emotional expression of happiness, fear, or anger. Whereas adults were more likely to select a happy partner on trust trials than on dominance trials and were more likely to select an angry partner on dominance trials than on trust trials, we found no evidence that children's choices reflected a combined influence of desirable trait and emotion. Follow-up experiments involving explicit trait judgments, explicit emotion recognition, and implicit first impression judgments in the context of intense emotional expressions provide valuable insights into the slow development of implicit trait judgments based on first impressions.