Analysis of occupational accidents for safety design.

BACKGROUND: Safety design covers proactive actions as it analyzes accident risks early in the enterprise life cycle, and considers the designer acting on accident prevention as a member of the construction team. OBJECTIVE: This paper proposes an accident investigation to establish links between accident causes and design to support Prevention through Design (PtD) tools. METHODS: This article analyzed more than a thousand severe and fatal accident cases in the construction sector. A systematic analysis method was structured based on descriptions of accident causes and measures that could be taken to avoid accidents. RESULTS: Analyzing the severe and fatal accidents, the safety measures implemented in the project design could avoid at least 23.6% of the events. As a result, the architectural and structural designs were more effective in accident prevention. The reference percentages and the design types that are more effective in preventing accidents are analyzed through a representative sample of the analysis of the accident. CONCLUSIONS: This research contributes to applying safety guidelines in design projects, directly assisting in project and construction management.

Association among 25-hydroxyvitamin D levels, hypertriglyceridemic-waist phenotype, and cardiometabolic markers in individuals with type 2 diabetes mellitus from regions with high solar incidence.

OBJECTIVE: To evaluate the relationship between vitamin D status and hypertriglyceridemic-waist (HTW) phenotype and cardiometabolic markers in individuals with type 2 diabetes mellitus (T2DM) living in regions with high solar incidence (10° south). METHODS: An observational, cross-sectional study, with 122 individuals with T2DM, of both sexes, aged between 19 and 59 years, residing in Sergipe/Brazil. Measurements included serum 25-hydroxyvitamin D (25[OH]D), glucose, insulin, total cholesterol, LDL-c, HDL-c, triacylglycerols, blood pressure, body mass index, %body fat, and waist circumference. Participants were classified by the presence or absence of the HTW phenotype, according to increased waist circumference and triacylglycerols concentrations. Logistic and linear regression models were applied to verify the association among the concentration of 25(OH)D, HTW phenotype, and lipid profile variables. RESULTS: Triacylglycerols concentrations (p = .013) and %body fat (p = .011) were higher in women with serum 25(OH)D insufficient/deficient than in those with adequate 25(OH)D levels. Individuals with serum 25(OH)D insufficiency/deficiency were 2.595 times more likely to present the HTW phenotype than those with adequate 25(OH)D levels (p = .021). Additionally, a negative association was observed between the concentration of 25(OH)D and total cholesterol (Beta = -0.204, p = .049). CONCLUSION: Insufficiency/deficiency of serum 25(OH)D in individuals with T2DM increases the chances of developing the HTW phenotype.

Supplementation of vitamin D isolated or calcium-associated with bone remodeling and fracture risk in postmenopausal women without osteoporosis: A systematic review of randomized clinical trials.

Menopause and vitamin D deficiency increase bone reabsorption and bone fracture risk in women in postmenopause, and vitamin D supplementation may improve bone health and decrease bone fracture risk. This study aims to discuss the effect of vitamin D supplementation, isolated or calcium-associated, on remodeling and fracture risk bone in women in postmenopause without osteoporosis. This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO database registration: CRD42022359796). A search was conducted in four databases and gray literature using MeSH and similar terms related to supplements, vitamin D, calcium, remodeling, and fracture bone, without the restriction of language and year of publication. A total of 3460 studies were identified, and nine were selected. Vitamin D supplementation increased 25-hydroxyvitamin D levels ≥10 ng/mL and decreased parathyroid hormone secretion dependent on baseline levels. The doses of 400 IU of vitamin D improved the percentage of carboxylated osteocalcin, whereas 800 to 1000 IU combined with calcium resulted in reduced, improved, or maintained bone mineral density and reduced alkaline phosphatase levels. However, 4000 IU alone or combined with calcium for 6 mo did not improve C-telopeptide and procollagen type 1 peptide levels. Additionally, 15 000 IU/wk increased the cortical area of metacarpal bone, whereas 500 000 IU of vitamin D annually for 5 y did not contribute to reducing the fracture risk and falls. Only one study found a reduction in fracture risk (dose of 800 IU of vitamin D plus 1200 mg of calcium). Thus, the vitamin D supplementation, alone or calcium-associated, improved the status of 25-hydroxyvitamin D and bone remodeling, but it was not possible to assert that it reduced fracture bone risk in postmenopausal women.

Digital tools for prevention through design application: A systematic review.

BACKGROUND: Prevention through Design (PtD) is a safety initiative that increases the ability of eliminating risks before construction. Implementing digital tools for PtD is an innovative way to help identify embedded risk in design phase by automating a process that is currently time consuming and extensively dependent on designers' experience. However, there is a lack of known digital safety tools available to professionals. OBJECTIVE: The aim of this article is to systematically review published research on the development of digital tools for PtD in order to point out existing processes and limitations. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines were used to search publications in Scopus database. Initially, 148 publications were found, but after applying the filters, thirteen publications were read and included in this review. RESULTS: Quantitative results showed few publications and quantitative results detailed the studied digital tools workings and what limitations prevent their full implementation by designers. CONCLUSION: Although 53.84% of methods are automatic, existing barriers such as the inability to consider schedule, and to provide a complete database challenge the validity of these tools. Therefore, PtD still poses a research gap for future research on safety matters.

The impact of an emergency department peer navigator (EDPN) program in improving clinical outcomes and healthcare utilization in an urban setting.

INTRODUCTION: Emergency Department Peer Navigator Programs (EDPN) have been shown to increase the prescribing of medications for opioid use disorder (MOUD) and improve linkage to addiction care. However, what is not known is whether it can improve overall clinical outcomes and healthcare utilization in patients with OUD. METHODS: This is a single-center, IRB approved, retrospective cohort study using patients with OUD enrolled in our peer navigator program from 11/7/19 to 2/16/21. On an annual basis, we determined MOUD clinic follow-up rates and clinical outcomes in those patients who utilized our EDPN program. Finally, we also looked at the social determinants of health factors (e.g., race, status of medical insurance, lack of housing, access to phone and/or internet, employment, etc.) that impact our patients clinical outcomes. ED and inpatient provider notes were reviewed to determine causes of ED visits and hospitalizations one year before and after enrollment into the program. The clinical outcomes of interest were number of ED visits from all-causes, number of ED visits from opioid-related causes, number of hospitalizations from all-causes, and number of hospitalizations from opioid-related causes one year after enrollment into our EDPN program, subsequent urine drug screens, and mortality. Demographic and socioeconomic factors (age, gender, race, employment, housing, insurance status, access to phone) were also analyzed to determine if any were independently associated with clinical outcomes. Death and cardiac arrests were noted. Clinical outcomes data were described using descriptive statistics and compared using t-tests. RESULTS: 149 patients with OUD were included in our study. 39.6% had an opioid-related chief complaint at their index ED visit; 51.0% had any recorded history of MOUD and 46.3% had history of buprenorphine use. 31.5% had buprenorphine given in the ED with individual doses ranging from 2 to 16 mg and 46.3% were provided with a buprenorphine prescription. The average number of ED visits 1-year pre vs post enrollment, respectively, for all-causes was 3.09 vs 2.20 (p < 0.01); for opioid related complications 1.80 vs 0.72 (p < 0. 01). The average number of hospitalizations 1-year pre and post enrollment, respectively, for all-causes was 0.83 vs 0.60 (p = 0.05); for opioid related complications 0.39 vs 0.09 (p < 0.01). ED visits from all-causes decreased in 90 (60.40%) patients, had no change in 28 (18.79%) patients, and increased in 31 (20.81%) patients (p < 0.01). ED visits from opioid-related complications decreased in 92 (61.74%) patients, had no change in 40 (26.85%) patients, and increased in 17 (11.41%) (p < 0.01). Hospitalizations from all causes decreased in 45 (30.20%) patients, had no change in 75 patients (50.34%), and increased in 29 (19.46%) patients (p < 0.01). Lastly, hospitalizations from opioid-related complications decreased in 31 (20.81%) patients, had no change in 113 (75.84%) patients, and increased in 5 (3.36%) patients (p < 0.01). There were no socioeconomic factors that had a statistically significant association with clinical outcomes. Two patients (1.2%) died within 1 year after study enrollment. CONCLUSIONS: Our study found that there was an association between implementation of an EDPN program and decreases in ED visits and hospitalizations from both all-causes as well as from opioid-related complications for patients with opioid use disorder.

Magnesium Status and Dietary Patterns Associated with Glycemic Control in Individuals with Type 2 Diabetes Mellitus.

Hypomagnesemia and unhealthy eating patterns are associated with poor glycemic control in individuals with type 2 diabetes mellitus (T2DM). This study aimed to associate magnesium status and dietary patterns with glycemic control in T2DM individuals. This cross-sectional study included 147 individuals with T2DM, aged between 19 and 59 years, of both sexes, residents in Sergipe/Brazil. The BMI, waist circumference, %body fat, plasma magnesium, serum glucose, insulin, %HbA1c, triacylglycerol, total cholesterol, LDL-c, and HDL-c were analyzed. Eating patterns were identified using a 24-h recall method. Logistic regression models were used to verify the association of magnesium status and dietary patterns with markers of glycemic control by adjusting for sex, age, time of T2DM diagnosis, and BMI. A P value < 0.05 was considered significant. Magnesium deficiency increased the chance of elevated %HbA1c by 5.893-fold (P = 0.041). Three main dietary patterns were identified: mixed (MDP), unhealthy (UDP), and healthy (HDP). UDP also increased the chance of elevated %HbA1c levels (P = 0.034). T2DM individuals' who presented magnesium deficiency had a higher chance of elevated %HbA1c levels (8.312-fold) and those in the lowest quartile (Q) of the UDP (Q1: P = 0.007; Q2: P = 0.043) had a lower chance of elevated %HbA1c levels. However, the lower quartiles of the HDP were associated with a greater chance of alterations in the %HbA1c level (Q1: P = 0.050; Q2: P = 0.044). No association was observed between MDP and the variables studied. Magnesium deficiency and UDP were associated with a higher chance of inadequate glycemic control in T2DM individuals.

Evidências científicas sobre comunicação com pacientes em unidades de terapia intensiva / Scientific evidence on communication with patients in intensive care units / Evidencia científica sobre la comunicación con pacientes en unidades de tratamiento intensivo

Introdução: O tubo endotraqueal bloqueia as pregas vocais quando o paciente está em ventilação, impossibilitando a fala. Muitos pacientes relatam que lutam para se fazer entender. Pacientes em unidades de terapia intensiva geralmente estão mais conscientes e alertas quando estão em ventilação mecânica do que em anos anteriores devido aos muitos benefícios potenciais de estarem sob menos sedação. Objetivo: avaliar o conhecimento prévio sobre interação e comunicação entre profissionais de saúde e pacientes conscientes e alertas sob ventilação mecânica em unidades de terapia intensiva. Método: Trata-se de uma revisão de literatura seguindo as etapas de uma revisão integrativa. Estudos publicados entre 2017 e 2022 foram identificados em ferramentas e bases de dados: Scielo, Lilacs, Ibecs, Medline e PubMed. A primeira pesquisa retornou 1273 referências únicas. Os critérios de inclusão consistiram em estudos empíricos ou relacionados às interações entre profissionais de saúde e pacientes maiores de 18 anos em ventilação mecânica, escritos em inglês, espanhol ou português. A amostra foi composta por 8 artigos. Os descritores utilizados foram: experiências com comunicação, ventilação mecânica, trocas de comunicação, unidade de terapia intensiva, enfermagem, equipe multidisciplinar. Resultados: Uma variedade de meios de comunicação que parecem ter algum efeito sobre os pacientes devem ser disponibilizados nas unidades de terapia intensiva. Conclusão: Abordagens mais multidisciplinares em estudos futuros podem aprimorar o conhecimento na área. A educação em saúde do pessoal da unidade de terapia intensiva no uso de tais auxílios deve ser um campo prioritário, assim como a implementação de diversos meios de comunicação.

Introduction: The endotracheal tube blocks the vocal folds when the patient is ventilated, making speech impossible. Many patients report that they struggle to make themselves understood. Patients in intensive care units are generally more aware and alert when they are on mechanical ventilation than in previous years because of the many potential benefits of being under less sedation. Objective: To evaluate prior knowledge about interaction and communication between health professionals and conscious patients and alerts under mechanical ventilation in intensive care units. Method: This is a literature review following the steps of an integrative review. Studies published between 2017 and 2022 have been identified in tools and databases: Scielo, Lilacs, Ibecs, Medline and PubMed. The first survey returned 1273 unique references. The inclusion criteria consisted of empirical studies or studies related to interactions between health professionals and patients over 18 years of age on mechanical ventilation, written in English, Spanish or Portuguese. The sample consisted of 8 articles. The descriptors used were: communication experiments, mechanical ventilation, communication exchanges, intensive care unit, nursing, multidisciplinary team. Results: A variety of communication media that appear to have some effect on patients should be made available in intensive care units. Conclusion: More multidisciplinary approaches in future studies can improve knowledge in the area. The health education of the staff of the intensive care unit in the use of such aids should be a priority field, as well as the implementation of various means of communication.

Introducción: el tubo endotraqueal bloquea las uñas de la voz cuando el paciente está en ventilación, haciendo imposible el habla. Muchos pacientes informan que luchan por hacerse entender. Los pacientes en unidades de cuidados intensivos son generalmente más conscientes y alerta cuando están en ventilación mecánica que en años anteriores debido a los muchos beneficios potenciales de estar bajo menos sedación. Objetivo: evaluar el conocimiento previo de la interacción y comunicación entre profesionales de la salud y pacientes conscientes y alertas bajo ventilación mecánica en unidades de cuidados intensivos. Método: Esta es una revisión de la literatura que sigue las etapas de una revisión integradora. Los estudios publicados entre 2017 y 2022 se identificaron en herramientas y bases de datos: Scielo, Lilacs, Ibecs, Medline y PubMed. La primera encuesta arrojó 1273 referencias únicas. Los criterios de inclusión consistieron en estudios empíricos o estudios relacionados con las interacciones entre profesionales de la salud y pacientes mayores de 18 años en ventilación mecánica, escritos en inglés, español o portugués. La muestra consistió en 8 artículos. Los descriptores utilizados fueron: experimentos con comunicación, ventilación mecánica, intercambios de comunicación, unidad de terapia intensiva, enfermería, equipo multidisciplinario. Resultados: En las unidades de cuidados intensivos debe estar disponible una variedad de medios que parecen tener algún efecto en los pacientes. Conclusión: La adopción de enfoques más multidisciplinarios en estudios futuros puede mejorar los conocimientos en la materia. La educación sanitaria del personal de la unidad de cuidados intensivos en el uso de esa ayuda debería ser una esfera prioritaria, al igual que la aplicación de diversos medios de comunicación.

First Report of Lasiodiplodia brasiliensis Causing Root Rot on Watermelon in Brazil.

Watermelon (Citrullus lanatus (Thumb.) Matsum. & Nakai) is an important crop in Brazil both for export and domestic consumption. In October 2019, watermelon plants showing decline and root rot symptoms were surveyed in 16 commercial fields in Baraúna's municipality (Rio Grande do Norte, Brazil). The disease prevalence was 12.5%, and the average incidence was 5%. Affected root segments were cut into small pieces and surface-disinfected with 70% ethyl alcohol and 1.5 % NaOCl for 1 and 2 min, respectively. Tissues were plated onto potato dextrose agar (PDA) and incubated at 25°C for 7 days. Fungal colonies developed from the infected tissues were dark or greyish, and pure cultures were obtained by hyphal tip isolation technique. Six fungal isolates with the same morphology were obtained. Two of them were selected for morphological and molecular characterization (CFC-1123 and CFC-1124). Isolates grew rapidly in PDA, covering the entire surface of the Petri dishes within 3 days. The aerial mycelium was initially white, turning dark greenish-gray after 4 to 5 days of incubation at 25°C in the dark. Isolates produced pycnidia and conidia in water-agar medium with sterilized pine needles after 30 days of incubation at 25°C under near-UV light. The conidia were initially hyaline and brown with central transverse septum and longitudinal streaks when mature. Conidia were ellipsoid to oval (22.83 ± 3.1 µm long and 11.58 ± 1.5 µm wide). Based on morphological features, the isolates were initially identified as Lasiodiplodia sp. (Phillips et al. 2013). To confirm the identification, genomic DNA was extracted and the internal transcribed spacer (ITS) region as well as fragments of the translation elongation factor 1-α (TEF) and ß-tubulin 2 (TUB) genes were amplified using the primer pairs ITS1/ITS4 (White et al. 1990), EF1-728F/EF1-986R (Carbone and Kohn 1999) and Bt2a/Bt2b (Glass and Donaldson 1995), respectively. The sequences were deposited in GenBank under accession numbers OL841380, OL865376 and OL890691 for CFC-1123, and OL841381, OL865377 and OL890692 for CFC-1124. Maximum likelihood phylogenetic analysis of the concatenated sequences of ITS, TEF and TUB gene regions of some reference sequences and ex-types of Lasiodiplodia spp. was performed. Phylogenetic analysis revealed that the isolates grouped in the L. brasiliensis clade (Netto et al. 2014) with 80/79% of bootstrap. The isolates were deposited in the Culture Collection of Phytopathogenic Fungi from Cariri (CFC) at the Universidade Federal do Cariri (Crato, Brazil). Pathogenicity of the two isolates was determined using colonized wheat grains as inoculum source. One watermelon seed (cv. Crimson Sweet) was placed in a sterile plastic pot (500-mL) filled with 6 cm layer of a substrate composed of soil and Tropstrato® (5:1 w/w). Three wheat grains (50 mg) colonized with each isolate were placed 10 mm above the seed and covered with the substrate. Control pots were inoculated only with sterile wheat grains. There were five replicates for each isolate. The pots with seedlings were maintained in a greenhouse at 28 ± 2°C under natural light conditions. The inoculated seedlings showed poor growth, withering and drying leaves 45 days after inoculation (DAI), and subsequently root rot symptoms and death at 60 DAI. Control seedlings remained asymptomatic. The pathogen was re-isolated from all inoculated seedlings and identified by conidia morphology to fulfill Koch's postulates. Lasiodiplodia brasiliensis has been reported to cause postharvest rot and gummosis of watermelon (Farr and Rossman 2022). However, to our knowledge, this is the first report of watermelon decline caused by this fungus in Brazil and worldwide. This finding must be considered for developing efficient control strategies for the disease.

Acute coronary syndrome and transient global amnesia with sumatriptan.

Triptans are potent serotoninergic vasoconstrictors. They are generally avoided in elderly patients age greater than 65 or in patients with a history of CAD. Although there are reported cases of Acute Coronary Syndrome (ACS) or Transient Global Amnesia (TGA) in patients after ingesting therapeutic doses of triptan or dihydroergotamine, this is the first case report, up to our knowledge, of a patient, who had no previous cardiac history, that was diagnosed with both ACS and TGA. A 59-year-old woman with a long-standing history of migraine, gastroesophageal reflux disease, and hypothyroidism, presented to the Emergency Department (ED) complaining of amnesia, chest pain, and left arm numbness after ingesting a single dose of oral sumatriptan approximately 1-2 h prior to arrival. She had no recollection of the events that occurred after taking sumatriptan. No acute laboratory abnormalities were found except for an elevated troponin, which continued to trend upwards. Her EKG had no ST-T wave abnormalities. She was diagnosed with Acute Coronary Syndrome (ACS), non-ST elevation MI. She had a negative noncontrast CT head. Neurology was consulted for her amnesia and diagnosed her with Transient Global Amnesia (TGA). They recommended discontinuing sumatriptan and beginning topiramate as a prophylactic therapy. There is an increasing number of reports delineating sumatriptan's adverse effects. Emergency medicine physicians should promptly recognize the toxic effects and adverse reactions from triptans. Sumatriptan-induced vasoconstriction may lead to cardiac and cerebral ischemic events.

Role of food fortification with vitamin D and calcium in the bone remodeling process in postmenopausal women: a systematic review of randomized controlled trials.

CONTEXT: Foods containing vitamin D reduce the deficiency of this vitamin and improve bone turnover. OBJECTIVE: To discuss effects of the intake of vitamin D-fortified foods in isolated form or associated with calcium on bone remodeling in postmenopausal women. DATA SOURCES: PubMed, Lilacs, Scopus, and Bireme databases. OpenThesis and Google Scholar were searched as "grey literature". Medical subject headings or similar terms related to food fortified with vitamin D and bone in postmenopausal women were used. DATA EXTRACTION: Information was collected on study methodology and characteristics of studied populations; dosage; the food matrix used as the fortification vehicle; duration of intervention; dietary intake; 25-hydroxyvitamin D [25(OH)D] levels; serum parathyroid hormone (PTH) concentrations; bone resorption and/or formation markers (ie, carboxy terminal cross-linked telopeptide of type I collagen [CTX], tartrate-resistant acid phosphatase isoform 5b [TRAP5b], and procollagen type 1 N-terminal propeptide [P1NP]); main results; and study limitations. DATA ANALYSIS: Five randomized controlled trials involving postmenopausal women were included. The mean ages of participants ranged from 56.1 to 86.9 years. Daily consumption of soft plain cheese fortified with 2.5 µg of vitamin D3 and 302 mg of calcium for 4 weeks resulted in a mean increase of 0.8 ng/mL in 25(OH)D and 15.9 ng/mL in P1NP levels compared with baseline, and decreased CTX, TRAP5b, and PTH values. A similar intervention for 6 weeks, using fortified cheese, showed a reduction only in TRAP5b values (-0.64 U/L). Yogurt fortified with 10 µg of vitamin D3 and 800 mg of calcium did not change P1NP values after 8 weeks of intervention, but was associated with decreases of 0.0286 ng/mL and 1.06 U/L in PTH and TRAP5b, respectively. After 12 weeks of eating the fortified yogurt, 25(OH)D levels increased by a mean of 8.8 ng/mL and PTH levels decreased in by a mean of 0.0167 ng/mL. CONCLUSIONS: The interventions contributed toward the improvement of the bone resorption process but not to the bone formation process in postmenopausal women. PROSPERO REGISTRATION NUMBER: CRD42019131976.

The Impact of a Peer-Navigator Program on Naloxone Distribution and Buprenorphine Utilization in the Emergency Department.

Objectives: In recent years many emergency departments (EDs) have adopted interventions to help patients with opioid use disorder (OUD), particularly buprenorphine initiation and ED-based peer recovery support. There are limited data on the impact of peer navigators on provider naloxone kit distribution and buprenorphine utilization. We aimed to examine the impact of a peer recovery program on naloxone kit distribution and buprenorphine administration. Methods: This was a retrospective study analyzing the change in naloxone kits distributed as well as buprenorphine administrations. Data on naloxone kit and buprenorphine administrations was generated every month between November 2017 and February 2021. Time periods were as follows: implementation of guidelines for buprenorphine and naloxone kits, initiation of the navigator program, and first wave of COVID-19. Numbers of naloxone kits distributed and buprenorphine administrations per month were computed. Results: Between November 2017 and December 2020, there was a significant increase overtime among the 238 naloxone kits distributed (p < 0.0001). Between implementation of guidelines and introduction of peer navigators, there were 49 kits distributed, compared to an increase overtime among 235 kits when the navigator program began (p = 0.0001). There was also a significant increase overtime among 1797 administrations of buprenorphine (p < 0.0001). Administrations increased by 22.4% after implementation of the navigator program-a total of 787 compared to 643 post guideline (p = 0.007). Conclusion: Peer recovery support programs for patients with OUD can have an impact on administration of naloxone kits and buprenorphine. Future studies should determine whether these programs can cause a long-term culture change in the ED.

High-fat diet and caffeine interact to modulate bone microstructure and biomechanics in mice.

AIMS: Although excessive fat and caffeine intake are independent risk factors for bone microstructural and functional disturbances, their association remains overlooked. Thus, we investigated the impact of high-fat diet (HFD) and caffeine alone and combined on serum lipid profile, bone microstructure, micromineral distribution and biomechanical properties. METHODS: Forty female C57BL/6 mice were randomized into 4 groups daily treated for seventeen weeks with standard diet (SD) or HFD (cafeteria diet) alone or combined with 50 mg/kg caffeine. KEY FINDINGS: The association between HFD and caffeine reduced the weight gain compared to animals receiving HFD alone. Caffeine alone or combined with HFD increases total and HDL cholesterol circulating levels. HFD also reduced calcium, phosphorus and magnesium bone levels compared to the groups receiving SD, and this reduction was aggravated by caffeine coadministration. From biomechanical assays, HFD combined with caffeine increased bending strength and stiffness of tibia, a finding aligned with the marked microstructural remodeling of the cortical and cancellous bone in animals receiving this combination. SIGNIFICANCE: Our findings indicated that HFD and caffeine interact to induce metabolic changes and bone microstructural remodeling, which are potentially related to bone biomechanical adaptations in response to HFD and caffeine coadministration.

A review of the existing literature on buprenorphine pharmacogenomics.

Buprenorphine is an effective treatment for opioid dependence; however, it demonstrates individual variability in efficacy. Pharmacogenomics may explain this drug response variability and could allow for tailored therapy on an individual basis. The Food and Drug Administration and the Clinical Pharmacogenomics Implementation Consortium have guidelines on pharmacogenomic testing for some opioids (e.g., codeine); however, no guidelines exist for the partial opioid agonist buprenorphine. Pharmacogenomic testing targets for buprenorphine include pharmacodynamic genes like the mu-opioid receptor (MOP receptor) and catechol-O-methyltransferase (COMT), as well as the pharmacokinetic genes like the CYP enzymes. In this review we identified genotypes in patients with opioid addiction receiving buprenorphine that may result in altered therapeutic dosing and increased rate of relapse. The OPRM1 A118G single nucleotide polymorphism (SNP rs1799971) gene variant encoding the N40D MOP receptor has been associated with variable efficacy and response to treatment in both adult and neonatal patients receiving buprenorphine for treatment of opioid withdrawal. An SNP associated with rs678849 of OPRD1, coding for the delta opioid receptor, was associated with opioid relapse as indicated by opioid positive urine drug screens; there was also sex specific SNP identified at rs581111 and rs529520 in the European American population. COMT variability, particularly in rs4680, has been associated with length of stay and need for opioid treatment in patients with neonatal abstinence syndrome. Variations of the pharmacokinetic gene for CYP3A4 showed that the ultrarapid metabolizer phenotype required higher doses of buprenorphine. Genotyping of patients may allow us to appropriately tailor buprenorphine therapy to individual patients and lead to improved patient outcomes; however, further research on the pharmacogenomics of buprenorphine is needed.

Effects of Extended-Release Methylphenidate Treatment on Cognitive Task Performance in Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder.

Objective: To examine the effectiveness of four doses of psychostimulant medication, combining extended-release methylphenidate (ER-MPH) in the morning with immediate-release MPH (IR-MPH) in the afternoon, on cognitive task performance. Method: The sample comprised 24 children (19 boys and 5 girls) who met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR) criteria for an autism spectrum disorder (ASD) on the Autism Diagnostic Interview-R and the Autism Diagnostic Observation Schedule, and had significant symptoms of attention-deficit/hyperactivity disorder (ADHD). This sample consisted of elementary school-age, community-based children (mean chronological age = 8.8 years, SD = 1.7; mean intelligence quotient = 85; SD = 16.8). Effects of placebo and three dose levels of ER-MPH (containing 0.21, 0.35, and 0.48 mg/kg equivalent of IR-MPH) on cognitive task performance were compared using a within-subject, crossover, placebo-controlled design. Each of the four MPH dosing regimens (placebo, low-dose MPH, medium-dose MPH, and high-dose MPH) was administered for 1 week; the dosing order was counterbalanced across children. Results: MPH treatment was associated with significant performance gains on cognitive tasks tapping sustained attention, selective attention, and impulsivity/inhibition. Dose/response was generally linear in the dose range studied, with no evidence of deterioration in performance at higher MPH doses in the dose range studied. Conclusion: The results of this study suggest that MPH formulations are associated with significant improvements on cognitive task performance in children with ASD and ADHD.

The Case of Flecainide Toxicity: What to Look for and How to Treat.

BACKGROUND: Flecainide is a class Ic antidysrhythmic agent used to prevent and treat both ventricular and supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, and Wolff-Parkinson-White syndrome. Flecainide can cause serious side effects, including cardiac arrest, dysrhythmias, and heart failure. Despite its growing use, the presenting signs and symptoms of flecainide toxicity are not familiar to most clinicians. In particular, our patient's particular presentation of acute kidney injury (AKI) resulting in flecainide accumulation is high risk for missed diagnosis in the emergency department. CASE REPORT: A 58-year-old woman presented with altered mental status and hypoxia that was later found to be secondary to sepsis. Medical history was notable for atrial fibrillation, for which she was on flecainide. Laboratory results were notable for hypokalemia and an AKI. Her wide complex tachycardia on admission was ultimately attributed to flecainide toxicity in the setting of AKI. Six days after presentation, it was found that her flecainide level was in the toxic range at 2.02 µg/mL (normal range 0.20-1.00 µg/mL, toxic >1.50 µg/mL). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Flecainide intoxication is rare but serious due to the potential for cardiogenic shock. Its diagnosis can be difficult, as the flecainide serum level may take days to result. This case demonstrates the necessity of keeping flecainide toxicity on the physician's differential for patients who are taking the drug, as well as what electrocardiogram findings suggest it as the etiology. Treatment can be lifesaving if initiated promptly.

The Global Educational Toxicology Toolkit (GETKIT): A 1-Day Course for Teaching Poisoning Essentials in Low- and Middle-Income Countries (LMIC): Course Development and Pilot Data Analysis.

INTRODUCTION: Worldwide an estimated one million deaths occur annually as a result of poisoning. Internationally there is a lack of toxicology training programs, especially in resource poor settings. We developed a one-day, interactive toxicology curriculum for healthcare practitioners in countries lacking clinical toxicology training and evaluated its feasibility and effectiveness for knowledge dissemination. METHODS: GETKIT was developed with 3 sections: didactics, hands on toxicology case lab, and technology clinic. The investigators, who are medical toxicologists,created 23 didactic lectures and 42 workshop cases. All materials were peer reviewed by 5 senior medical toxicologists for content validity. Participants atpilot sites were given pre-course, post-course, and 3-month follow-up tests and surveys. RESULTS: GETKIT was delivered internationally at 7 sites between November 2017 and April 2018. There were 186 total participants. One hundred and ten participants (59%) reported their hospital lacked a clinical toxicology service. The median post course score 12 (60%), IQR (6,14) was significantly higher compared to the pre-course score 9 (45%), IQR (6,11) (p < 0.0001). There was a significantly higher median 3-month post course score 13 (65%), IQR (8,14) vs. a median pre course score of 9 (45%), IQR (6,11) (p 0.0005). At 3-month follow up 86% of participants reported GETKIT had changed their clinical practice. CONCLUSIONS: An improvement in and retention of medical toxicology knowledge was demonstrated with the GETKIT course. It also conferred improvement in selfreportedpoisoning management practices in participants from low resource settings.

Characterizing Chemical Terrorism Incidents Collected by the Global Terrorism Database, 1970-2015.

BACKGROUND: The Global Terrorism Database (GTD) is an open-source database on terrorist incidents around the world since 1970, and it is maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism (START; College Park, Maryland USA), a US Department of Homeland Security Center of Excellence. The consortium reviews media reports to determine if an event meets eligibility to be categorized as a terrorism incident for entry into the database. OBJECTIVE: The objective of this study was to characterize chemical terrorism incidents reported to the GTD and understand more about the kinds of chemical agents used, the associated morbidity and mortality, the geography of incidents, and the intended targets. METHODS: Chemical terrorism incidents from 1970 through 2015 were analyzed by chemical agent category, injury and fatality, geographic region, and target. RESULTS: During the study period, 156,772 terrorism incidents were reported to the GTD, of which 292 (0.19%) met the inclusion criteria for analysis as a chemical terrorism incident. The reported chemical agent categories were: unknown chemical (30.5%); corrosives (23.3%); tear gas/mace (12.3%); unspecified gas (11.6%); cyanide (8.2%); pesticides (5.5%); metals (6.5%); and nerve gas (2.1%). On average, chemical terrorism incidents resulted in 51 injuries (mean range across agents: 2.5-1,622.0) and seven deaths (mean range across agents: 0.0-224.3) per incident. Nerve gas incidents (2.1%) had the highest mean number of injuries (n = 1,622) and fatalities (n = 224) per incident. The highest number of chemical terrorism incidents occurred in South Asia (29.5%), Western Europe (16.8%), and Middle East/North Africa (13.0%). The most common targets were private citizens (19.5%), of which groups of women (22.8%) were often the specific target. Incidents targeting educational institutions often specifically targeted female students or teachers (58.1%). CONCLUSIONS: Chemical terrorism incidents rarely occur; however, the use of certain chemical terrorism agents, for example nerve gas, can cause large mass-causality events that can kill or injure thousands with a single use. Certain regions of the world had higher frequency of chemical terrorism events overall, and also varied in their frequencies of the specific chemical terrorism agent used. Data suggest that morbidity and mortality vary by chemical category and by region. Results may be helpful in developing and optimizing regional chemical terrorism preparedness activities.

Bismuth Subsalicylate Coagulopathy in a Patient with Chronic Liver Disease.

Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient's high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease.