Posterior Reversible Encephalopathy Syndrome Presenting as Delirium With Psychosis and Agitation in the Postpartum Period.

Posterior reversible encephalopathy syndrome (PRES), which was first described in 1996, is a neurologic condition characterized by a combination of clinical and neuroimaging findings. PRES may arise in the context of preeclampsia, eclampsia, renal failure, and sepsis, among other conditions. Neuropsychiatric symptoms of PRES include altered mental status, agitation, and in some cases psychosis. PRES occurring in the postpartum period is understudied, especially with regard to its psychiatric manifestations. We aim to add to the literature a case of PRES associated with psychosis and agitation in a postpartum woman, highlighting clinical implications and offering suggestions for practice. A female in her late 20s, with no significant psychiatric or medical history, presented to the hospital at 29 weeks and one day of gestation following a witnessed seizure. She was found to be hypertensive and hyponatremic, was diagnosed with eclampsia, and underwent an emergent cesarean section due to fetal malpresentation. The next day, the patient developed paranoia with acute agitation, and the psychiatry team diagnosed her with delirium with psychosis/agitation secondary to her underlying medical condition. She required intramuscular medications for agitation, was placed in restraints, and was transferred to the ICU for sedation. Subsequently, CT and MRI scans of her head both indicated that she had developed PRES. The patient's delirium and psychotic behavior resolved after appropriate treatment of her eclampsia. To our knowledge, this case report is the second documented case in the literature, of a patient who presented with PRES characterized by agitation and psychotic features in the postpartum period. Due to the significant overlap in symptoms between delirium and postpartum psychosis, this case highlights the crucial importance of interdisciplinary collaboration for accurate diagnosis and prompt treatment of PRES in the postpartum period. The case also speaks to the importance of differentiating postpartum psychosis associated with a primary psychiatric disorder from delirium arising in postpartum patients with or without a previous psychiatric history.

Novel Escherichia coli-Infecting Bacteriophages Isolated from Uganda That Target Human Clinical Isolates.

Background: The antimicrobial resistance catastrophe is a growing global health threat and predicted to be worse in developing countries. Phages for Global Health (PGH) is training scientists in these regions to isolate relevant therapeutic phages for pathogenic bacteria within their locality, and thus contributing to making phage technology universally available. Materials and Methods: During the inaugural PGH workshop in East Africa, samples from Ugandan municipal sewage facilities were collected and two novel Escherichia coli lytic phages were isolated and characterized. Results: The phages, UP19 (capsid diameter ∼100 nm, contractile tail ∼120/20 nm) and UP30 (capsid diameter ∼70 nm, noncontractile tail of ∼170/20 nm), lysed ∼82% and ∼36% of the 11 clinical isolates examined, respectively. The genomes of UP19 (171.402 kb, 282 CDS) and UP30 (49.834 kb, 75 CDS) closely match the genera Dhakavirus and Tunavirus, respectively. Conclusion: The phages isolated have therapeutic potential for further development against E. coli infections.

Paradoxical Excitation Following Intravenous Lorazepam Administration for Alcohol Withdrawal - A Case Presentation and Literature Review.

Benzodiazepines are commonly used medications which are clinically useful towards the treatment of alcohol withdrawal, seizures, anxiety disorders, among other indications. Benzodiazepine use is also known to cause the rare phenomenon of paradoxical excitation whose mechanism has many postulated theories. We report this rare presentation of paradoxical excitation with the use of lorazepam in a 50-year-old male being treated for alcohol withdrawal. We also review the underlying pathophysiology, pharmacology, and current literature as it relates to this excitation. An inability to recognize this adverse effect and to appropriately withhold the agent may adversely affect a patient's course of treatment in the inpatient setting.

Isolated low toe-brachial index is associated with increased mortality and morbidity: a retrospective cohort study.

OBJECTIVE: The aim was to assess the prognostic impact of perfusion assessments including ankle-brachial Index (ABI) and toe-brachial Index (TBI) on survival of patients who present with diabetic foot ulceration and to analyse clinical outcomes when patients are categorised into three levels of limb ischaemia. METHOD: This was a retrospective cohort analysis of consecutive patients presenting with foot ulceration. Patients continued with their standard of care, after having baseline assessments of limb perfusion. Patients were retrospectively categorised into three groups according to baseline ABI and TBI: Group 1 (n=31) non-ischaemic (TBI≥0.75, ABI≥0.9), Group 2 (n=67) isolated low TBI with foot ischaemia (TBI<0.75, ABI≥0.90) and Group 3 (n=30) foot-leg ischaemia (TBI<0.75, ABI<0.90). RESULTS: A total of 128 patients took part in the study. Low TBI was associated with a significant decrease in patient survival (42±20 versus 51±16 months, p=0.011). There was a progressive and significant decline in mean patient survival time (51±16 versus 44±20 versus 39±22 months, respectively, for ANOVA across the three groups, p=0.04). Patients with isolated low TBI had angioplasty and bypass at a rate similar to that of patients in Group 3 (low ABI and low TBI). The proportion of angioplasties was significantly higher in the isolated low TBI (19.4% (13/67) versus the non-ischaemic 3.2% (1/31), p=0.033). Such revascularisation resulted in ulcer healing within the foot ischaemic group that was similar to the non-ischaemic group (68% versus 60% over 12 months, p=0.454). CONCLUSION: Regardless of ABI level, measurement of TBI identifies patients with isolated low TBI who require specialised care pathways and revascularisation to achieve ulcer healing that is similar to non-ischaemic patients.

Long tailed trions in monolayer MoS2: Temperature dependent asymmetry and resulting red-shift of trion photoluminescence spectra.

Monolayer molybdenum disulfide (MoS2) has emerged as a model system for studying many-body physics because the low dimensionality reduces screening leading to tightly bound states stable at room temperature. Further, the many-body states possess a pseudo-spin degree of freedom that corresponds with the two direct-gap valleys of the band structure, which can be optically manipulated. Here we focus on one bound state, the negatively charged trion. Unlike excitons, trions can radiatively decay with non-zero momentum by kicking out an electron, resulting in an asymmetric trion photoluminescence (PL) peak with a long low-energy tail and peak position that differs from the zero momentum trion energy. The asymmetry of the trion PL peak and resulting peak red-shift depends both on the trion size and a temperature-dependent contribution. Ignoring the trion asymmetry will result in over estimating the trion binding energy by nearly 20 meV at room temperature. We analyze the temperature-dependent PL to reveal the effective trion size, consistent with the literature, and the temperature dependence of the band gap and spin-orbit splitting of the valence band. This is the first time the temperature-dependence of the trion PL has been analyzed with such detail in any system.

2D Raman band splitting in graphene: Charge screening and lifting of the K-point Kohn anomaly.

Pristine graphene encapsulated in hexagonal boron nitride has transport properties rivalling suspended graphene, while being protected from contamination and mechanical damage. For high quality devices, it is important to avoid and monitor accidental doping and charge fluctuations. The 2D Raman double peak in intrinsic graphene can be used to optically determine charge density, with decreasing peak split corresponding to increasing charge density. We find strong correlations between the 2D 1 and 2D 2 split vs 2D line widths, intensities, and peak positions. Charge density fluctuations can be measured with orders of magnitude higher precision than previously accomplished using the G-band shift with charge. The two 2D intrinsic peaks can be associated with the "inner" and "outer" Raman scattering processes, with the counterintuitive assignment of the phonon closer to the K point in the KM direction (outer process) as the higher energy peak. Even low charge screening lifts the phonon Kohn anomaly near the K point for graphene encapsulated in hBN, and shifts the dominant intensity from the lower to the higher energy peak.

Band Gap Engineering with Ultralarge Biaxial Strains in Suspended Monolayer MoS2.

We demonstrate the continuous and reversible tuning of the optical band gap of suspended monolayer MoS2 membranes by as much as 500 meV by applying very large biaxial strains. By using chemical vapor deposition (CVD) to grow crystals that are highly impermeable to gas, we are able to apply a pressure difference across suspended membranes to induce biaxial strains. We observe the effect of strain on the energy and intensity of the peaks in the photoluminescence (PL) spectrum and find a linear tuning rate of the optical band gap of 99 meV/%. This method is then used to study the PL spectra of bilayer and trilayer devices under strain and to find the shift rates and Grüneisen parameters of two Raman modes in monolayer MoS2. Finally, we use this result to show that we can apply biaxial strains as large as 5.6% across micron-sized areas and report evidence for the strain tuning of higher level optical transitions.

Uniaxial Strain Redistribution in Corrugated Graphene: Clamping, Sliding, Friction, and 2D Band Splitting.

Graphene is a promising material for strain engineering based on its excellent flexibility and elastic properties, coupled with very high electrical mobility. In order to implement strain devices, it is important to understand and control the clamping of graphene to its support. Here, we investigate the limits of the strong van der Waals interaction on friction clamping. We find that the friction of graphene on a SiO2 substrate can support a maximum local strain gradient and that higher strain gradients result in sliding and strain redistribution. Furthermore, the friction decreases with increasing strain. The system used is graphene placed over a nanoscale SiO2 grating, causing strain and local strain variations. We use a combination of atomic force microscopy and Raman scattering to determine the friction coefficient, after accounting for compression and accidental charge doping, and model the local strain variation within the laser spot size. By using uniaxial strain aligned to a high crystal symmetry direction, we also determine the 2D Raman Grüneisen parameter and deformation potential in the zigzag direction.

Combinatorial approach to turbine bond coat discovery.

A nondestructive method for the high-throughput screening of novel bond coat materials has been developed. By using a suite of characterization techniques, including Raman spectroscopy, fluorescence spectroscopy, and X-ray diffraction, a rapid determination of thermally grown oxide phases and their protective capability over a continuous composition spread sample can be obtained. The methodology is validated with the Ni-Al system. The procedure developed in this work results in the rapid identification of bond coat composition regions in which the preferred thermally grown oxide, α-Al2O3, is nucleated thus significantly reducing the amount of phase space that needs to be explored in subsequent studies.

Optically stimulated luminescent dosimetry for high dose rate brachytherapy.

PURPOSE: The objective was to determine whether optically stimulated luminescent dosimeters (OSLDs) were appropriate for in vivo measurements in high dose rate brachytherapy. In order to make this distinction, three dosimetric characteristics were tested: dose linearity, dose rate dependence, and angular dependence. The Landauer nanoDot™ OSLDs were chosen due to their popularity and their availability commercially. METHODS: To test the dose linearity, each OSLD was placed at a constant location and the dwell time was varied. Next, in order to test the dose rate dependence, each OSLD was placed at different OLSD-to-source distances and the dwell time was held constant. A curved geometry was created using a circular Accuboost(®) applicator in order to test angular dependence. RESULTS: The OSLD response remained linear for high doses and was independent of dose rate. For doses up to 600 cGy, the linear coefficient of determination was 0.9988 with a response of 725 counts per cGy. The angular dependence was significant only in "edge-on" scenarios. CONCLUSION: OSLDs are conveniently read out using commercially available readers. OSLDs can be re-read and serve as a permanent record for clinical records or be annealed using conventional fluorescent light. Lastly, OSLDs are produced commercially for $5 each. Due to these convenient features, in conjunction with the dosimetric performance, OSLDs should be considered a clinically feasible and attractive tool for in vivo HDR brachytherapy measurements.

Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa.

BACKGROUND: Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978. Many governments in the first decade following the declaration responded by developing national programmes of community health workers (CHWs), but evaluations of these often demonstrated poor outcomes. As many CHW programmes have responded to the HIV/AIDS pandemic, international interest in them has returned and their role in the response to other diseases should be examined carefully so that lessons can be applied to their new roles. Over half of the deaths in African children under five years of age are due to malaria, diarrhoea and pneumonia - a situation which could be addressed through the use of cheap and effective interventions delivered by CHWs. However, to date there is very little evidence from randomised controlled trials of the impacts of CHW programmes on child mortality in Africa. Evidence from non-randomised controlled studies has not previously been reviewed systematically. METHODS: We searched databases of published and unpublished studies for RCTs and non-randomised studies evaluating CHW programmes delivering curative treatments, with or without preventive components, for malaria, diarrhoea or pneumonia, in children in sub-Saharan Africa from 1987 to 2007. The impact of these programmes on morbidity or mortality in children under six years of age was reviewed. A descriptive analysis of interventional and contextual factors associated with these impacts was attempted. RESULTS: The review identified seven studies evaluating CHWs, delivering a range of interventions. Limited descriptive data on programmes, contexts or process outcomes for these CHW programmes were available. CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions. CONCLUSIONS: CHW programmes could potentially achieve large gains in child survival in sub-Saharan Africa if these programmes were implemented at scale. Large-scale rigorous studies, including RCTs, are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions.

State requirements for physician emergency medical services providers.

OBJECTIVE: To describe requirements of physicians wishing to function as primary field emergency medical services (EMS) providers and variation of these requirements among states. METHODS: A simple mailed survey was developed and distributed to all 50 U.S. state EMS directors. The survey gathered information about each state's regulations concerning physicians performing as a primary EMS crew member. Data were entered into a Microsoft Excel spreadsheet and reported using simple descriptive statistics, including proportions and 95% confidence intervals (CIs). RESULTS: Forty-four (88%) of the states responded. In 32 states (73%), physicians can work as a primary member of either a basic life support (BLS) or an advanced life support (ALS) ambulance crew without any specific additional training. In 30 states (68%), physicians can work as a primary member of either a BLS or an ALS ambulance crew without any specific prehospital certification. All of the reporting states will allow a physician to become certified as an emergency medical technician (EMT) or paramedic and then work as a primary member of a BLS or ALS ambulance crew. Seventy-nine percent allow the provision of physician-level care on BLS ambulances, and 81% on ALS ambulances. There was no meaningful difference between the training requirements for becoming a certified BLS provider vs. a certified ALS provider. States were significantly less likely to require a skills examination of physicians wishing to become certified as a BLS provider (9%) compared with those wishing to become certified as an ALS provider (82%). CONCLUSION: Most states allow physicians to become certified prehospital care providers, although few states require physicians wishing to work as a primary EMS provider to do so, or even to undergo any specific EMS training. There is no national standardization of the preparatory requirements of physicians wishing to provide in-field EMS.

Two-year virologic outcomes of an alternative AIDS care model: evaluation of a peer health worker and nurse-staffed community-based program in Uganda.

BACKGROUND: There is growing concern about the human resources needed to care for increasing numbers of patients receiving antiretroviral therapy in resource-limited settings. We evaluated an alternative model, community-based, comprehensive antiretroviral program staffed primarily by peer health workers and nurses. METHODS: We conducted a retrospective cohort study of patients receiving antiretroviral therapy during the first 10 months of program enrollment beginning in late 2003. Virologic, immunologic, clinical, and adherence data were collected. RESULTS: Of 360 patients started on treatment, 258 (72%) were active and on therapy approximately 2 years later. Viral load testing demonstrated that 86% of active patients (211/246 tested) had a viral load <400 copies per milliliter. The median CD4 increase for active patients was 197 cells per cubic millimeter (interquartile range, 108-346). Patients with either a history of antiretroviral use or lack of CD4 response were more likely to experience virologic failure. Survival was 84% at 1 year and 82% at 2 years. World Health Organization stage 4 was predictive of both not sustaining therapy and increased mortality. CONCLUSIONS: A community-based antiretroviral treatment program in a resource-limited setting can provide excellent AIDS care over at least a 2-year period. A comprehensive program based upon peer health workers and nurses provides an effective alternative model for AIDS care.