Enhanced thromboprophylaxis in critically ill patients with COVID-19 infection.

Background: Patients with severe SARS-CoV-2 infection have been shown to have abnormal coagulation parameters and are at increased risk of thromboembolism. The optimal thromboprophylaxis regimen that minimizes thrombosis without increased risk of serious bleeding is uncertain. Objectives: To describe the efficacy and safety of increased intensity (enhanced) thromboprophylaxis in patients with COVID-19 admitted to the medical intensive care unit (MICU). Methods: This is a retrospective cohort analysis of patients with a diagnosis of COVID-19 admitted to the MICU of an urban safety net hospital. With the exception of patients being supported with extracorporeal membrane oxygenation or on chronic anticoagulation who received therapeutic dosing of anticoagulation, thromboprophylaxis was given as either enoxaparin or unfractionated heparin in doses higher than those recommended for standard prophylaxis, but lower than those used for therapeutic anticoagulation. Main results: Of the 120 patients managed with an enhanced thromboprophylaxis protocol, 6 (5%) experienced thromboembolism as a result of their COVID-19 disease (1 pulmonary embolus, 4 deep vein thromboses, and 1 arterial embolism). Four patients experienced major bleeding while receiving therapeutic anticoagulation. Conclusions: In critically ill patients with COVID-19, increased intensity (enhanced) thromboprophylaxis appears to be effective at preventing clinically significant thromboembolic events without an increased risk of serious bleeding.

Tryptophan depletion in SSRI-recovered depressed outpatients.

RATIONALE: Recently, a number of studies have challenged the finding that acute tryptophan depletion (TD) increases depressive symptoms in medicated, formerly depressed patients. The present study examined the effects of acute nutritional TD on remitted depressed patients currently treated with selective serotonin reuptake inhibitors. In an attempt to clarify conflicting earlier findings, the effects of a number of clinical variables on outcome were also investigated. METHODS: Ten patients underwent TD in a double-blind, controlled, balanced crossover fashion. The control session followed the procedure of Krahn et al. (1996 Neuropsychopharmacology 15:325-328). Sessions were 5-8 days apart. RESULTS: TD was significantly related to increased scores on clinician-rated depression and anxiety scales, and on self-rated depression, anxiety, and somatic symptoms. The control challenge had no effect, despite the fact that the reductions in plasma tryptophan during the control session were unexpectedly high. Some evidence was found for a threshold in the relationship between reduction of plasma tryptophan and mood response. CONCLUSIONS: The mood effect of TD in medicated, formerly depressed patients was confirmed. A threshold may exist for mood effects following TD, implying that recent negative findings may have been caused by insufficient depletion. No other predicting or mediating factors were identified, although the variable "history of response pattern to medication" deserves further study.

Pramipexole augmentation in the treatment of unipolar and bipolar depression: a retrospective chart review.

OBJECTIVE: To assess the effectiveness and safety of pramipexole as an adjunctive medication in refractory bipolar and unipolar depression in a naturalistic setting. METHODS: Retrospective chart review by psychiatrists on staff at a university hospital identified all patients who had received pramipexole. Response was based on moderate to marked improvement in the Clinical Global Impression-Improvement (CGI-I) scale. RESULTS: Pramipexole (mean dose 0.70 mg/d, mean duration 24.4 weeks) was effective in 6/12 (50.0%) of patients with bipolar depression, and 8/20 (40%) of patients with unipolar depression, mean duration of follow-up of 24.4 weeks. One case of transient hypomania was noted. Eight patients discontinued pramipexole due to lack of response and four due to side effects. CONCLUSIONS: Pramipexole, used as an adjunct to antidepressants or mood stabilizers, appeared to be effective and safe in the treatment of unipolar and bipolar depression. These uncontrolled, retrospective, naturalistic pilot data require confirmation by controlled research before conclusions can be made.

Anxiety disorders in major depression.

The prevalence and clinical impact of anxiety disorder comorbidity in major depression were studied in 255 depressed adult outpatients consecutively enrolled in our Depression Research Program. Comorbid anxiety disorder diagnoses were present in 50.6% of these patients and included social phobia (27.0%), simple phobia (16.9%), panic disorder (14.5%), generalized anxiety disorder ([GAD] 10.6%), obsessive-compulsive disorder ([OCD] 6.3%), and agoraphobia (5.5%). While both social phobia and generalized anxiety preceded the first episode of major depression in 65% and 63% of cases, respectively, panic disorder (21.6%) and agoraphobia (14.3%) were much less likely to precede the first episode of major depression than to emerge subsequently. Although comorbid groups were not distinguished by depression, anxiety, hostility, or somatic symptom scores at the time of study presentation, patients with comorbid anxiety disorders tended to be younger during the index episode and to have an earlier onset of the major depressive disorder (MDD) than patients with major depression alone. Our results support the distinction between anxiety symptoms secondary to depression and anxiety disorders comorbid with major depression, and provide further evidence for different temporal relationships with major depression among the several comorbid anxiety disorders.

An open trial of oral sildenafilin antidepressant-induced sexual dysfunction.

BACKGROUND: Sildenafil is a selective inhibitor of cyclic GMP-specific phosphodiesterase type 5 that has been associated with greater improvement of erectile function compared to placebo among men with erectile dysfunction. The goal of our study was to evaluate its efficacy in a small sample of outpatients with antidepressant-induced sexual dysfunction. METHODS: We studied the first 14 depressed outpatients (9 men and 5 women; mean age: 46.4 +/- 8.4) who were consecutively treated with oral sildenafil. Twelve of the 14 patients were treated with an SSRI and 2 with mirtazapine. All patients were prescribed oral sildenafil tablets at the initial dose of 50 mg q.d. p.r.n., with the possibility of increasing the dose to 100 mg q.d. p.r.n., if clinically indicated. We administered a sexual functioning questionnaire derived from the Guided Interview Questionnaire for females and males and from the Arizona Sexual Experience Scale to all patients before and after at least 4 weeks of treatment with oral sildenafil. The mean sildenafil dose in our 14 patients was 57 +/- 18 mg/day. RESULTS: All 14 subjects completed the follow-up assessments and no subjects discontinued the drug prematurely. We observed statistically significant improvements in all domains of sexual functioning, including libido, arousal, orgasm, sexual satisfaction, and (in males only) erectile function, with a 69% rate of patients reporting themselves as much or very much improved. Oral sildenafil treatment appeared to be very well tolerated, with only 1 out of 14 (7%) patients reporting an adverse event (hot flashes). CONCLUSIONS: Our findings of statistically significant improvements in all domains of sexual functioning in a sample of 14 men and women with antidepressant-induced sexual dysfunction suggest that this agent may represent an efficacious approach to this population.

Dignified dying as a nursing outcome.

The goal for humanistic end-of-life care is to maintain quality of life and personal dignity. The nursing outcome called "dignified dying" is defined as maintaining personal control and comfort with the approaching end of life and lists indicators for measuring this. These criteria enable nurses to measure the effectiveness of their nursing interventions, monitor patient progress over time, and summarize research data. This article describes the development of this outcome and illustrates its use with a case study.

Isolation and characterization of Melanoplus sanguinipes adipokinetic hormone: a new member of the AKH/RPCH family.

A neuropeptide hormone isolated from corpora cardiaca of Melanoplus sanguinipes was purified by HPLC. The HPLC fractions were examined for adipokinetic activity with an in vivo bioassay. A single large UV absorbent peak was active in the mobilization of lipid while the other HPLC fractions showed no detectable activity. This large peak had a retention time and amino acid composition identical to synthetic Lom-AKH-I which was analyzed in a parallel manner. The primary sequence structure, pGlu-Leu-Asn-Phe-Thr-Pro-Asn-Trp-Gly-Thr-NH2, was determined by automated gas-phase Edman degradation. The peptide was deblocked prior to sequencing using pyroglutamate aminopeptidase and the sequence was confirmed with mass spectrometry. The C-terminus of the peptide was determined to be blocked, as indicated by the lack of digestion with carboxypeptidase A. The knowledge of the primary sequence of Mes-AKH allows the use of a commercially available synthetic peptide and its antibodies for use in future research with Melanoplus sanguinipes.

Cold storage sensitizes hepatocytes to oxidative stress injury.

Liver cold storage leads to oxygen free radical production and reperfusion injury. Antioxidants are effective in suppression reperfusion injury in rat livers when used in the reperfusion medium. However, in clinical liver transplantation their effectiveness is not clear, which may be due to the way they are used (in the recipient). In this study we compare the effectiveness of antioxidants when used in the reperfusion medium versus the cold storage solution in isolated hepatocytes and the isolated perfused liver. Hepatocytes were cold stored in UW solution for 24 h. Oxidative stress, induced by t-butyl hydroperoxide (tBHP), was measured in the presence of one of five different antioxidants--deferoxamine (DFO), dithiothreitol (DTT), trolox, tocopherol, dimethylthiourea (DMTU)--in the reperfusion buffer or UW solution. Efficacy was judged by reduction in membrane damage (LDH release) during rewarming. Also, rat livers were cold stored for 48 h in UW solution (+/- antioxidant) and reperfused (+/- antioxidants). Efficacy was judged by the effect on enzyme release and bile production. Cold storage of hepatocytes for 24 h sensitized them to oxidative stress. The concentration of tBHP required to induce maximal cell death (80%-90% LDH release) was reduced from 1.3 mM (fresh cells) to 0.37 mM (LD-50 values). All antioxidants except DMTU suppressed oxyradical-induced LDH release when used in the reperfusion medium, but only DFO was effective when used in the UW solution. In the isolated perfused liver, DFO, DTT, and trolox were effective and suppressed enzyme release when added to the reperfusion buffer, but none were effective when used in the UW solution. We conclude that cold storage sensitizes liver cells to oxidative stress. The most effective antioxidant was the iron chealator, DFO, which was effective in the reperfusion buffer (isolated perfused sliver or hepatocytes) but not in the UW solution when tested in the isolated perfused liver. Suppression of reperfusion injury in liver transplantation could be obtained by antioxidant therapy. However, it is unclear how best to deliver the antioxidants to the site of oxyradical generation.

The influence of time of day on the foraging behavior of the honeybee, Apis mellifera.

The honeybee time sense, or Zeitgedächtnis, is highly adaptive, allowing bees to synchronize their foraging behavior with the peak time of daily floral nectar rhythms. Each foraging group within the honeybee colony shows a high degree of fidelity to one species of flower. Across the day, the temporal accuracy of foraging visits to experimental feeding times varies considerably, being nearly exact for morning-trained foraging groups but becoming less so for foraging groups trained later in the day. The evidence gained in this study suggests that the diel change in accuracy exhibited by foraging groups, which persists after the removal of many potential environmental time cues, is an endogenously driven behavior pattern. Furthermore, it appears that individual bees are continuously and accurately aware of the time of day, but are programmed to forage with greater anticipation to late-day food sources. Therefore, two separate processes contributing to the honeybee time sense are implicated. The first varies with time of day and determines the amount of anticipatory activity directed toward the food source. The second process is invariant across the day and is involved with the individual forager's continuous, accurate awareness of time.

Wing dimorphism in Gryllus rubens: genetic basis of morph determination and fertility differences between morphs.

The genetic basis of wing morph determination and fertility differences between wing morphs were studied in the wing-dimorphic cricket, Gryllus rubens. Using pair corsses, a significant effect of genotype on morph determination was documented in F3 progeny of field-collected crickets. The effect of genotype was significantly stronger in females than in males. Results are consistent with an earlier study (Zera and Tiebel 1988) showing that wing development is more strongly buffered from environmental variation in females. Segregation patterns were consistent with a polygenic mode of inheritance and provided no evidence for the existence of genes of major effect, maternal effects, or sex linkage. Only a weak morph x sex association was observed. These results contrast those of Walker (1987) where sex-linked loci of major effect on morph determination were identified in crosses between long-wing and short-wing-selected strains of G. rubens. Short-winged female G. rubens began ovipositing earlier and oviposited significantly more eggs than long-winged females during the first 24 days after adult eclosion. The greater reproductive output of the short-winged morph was due entirely to greater oviposition during the first two weeks after adult eclosion. Preliminary results indicate that flight may further accentuate the reduced reproductive output of long-winged versus short-winged females. These data provide the foundation for investigating the endocrine basis of morph-associated fertility variation in G. rubens and its mechanistic relationship with morph determination.