Case report: asenapine and anticholinergic toxicity.

While antipsychotic medications have long been associated with anticholinergic effects, asenapine has been purported to have no capacity for muscarinic cholinergic antagonism based on in vitro studies. Research in rat brain tissue has yielded different results, with one study finding more cholinergic M1-5 binding in the medial prefrontal cortex, dorsolateral frontal cortex and hippocampal CA1 and CA3 areas than would be predicted from in vitro findings. Moreover, it is structurally similar to other anticholinergic antipsychotics such as loxapine and, to a lesser degree, quetiapine, olanzapine and clozapine. This case report describes the anticholinergic toxidrome in a patient treated with benztropine and paroxetine at stable doses, with the emergence of the toxidrome after upward titration of asenapine. A broad differential was considered. With further consideration of the history, time-course, clinical features and physical examination, the presentation is most indicative of the anticholinergic toxidrome. Although not employed, physostigmine, the antidote for anticholinergic delirium, could help to differentiate this toxidrome and serve as a diagnostic and therapeutic intervention. We have presented this case to highlight the importance for clinicians to integrate history and bedside examination data with principles of pharmacology. In particular, asenapine should be added to the list of compounds with recognized anticholinergic potential.

Rapid development of interprofessional in situ simulation-based training in response to the COVID-19 outbreak in a tertiary-level hospital in Ireland: initial response and lessons for future disaster preparation.

Introduction: The first case of COVID-19 in Ireland was diagnosed on 29 February 2020. Within the same week, our Department of Anaesthesia and Critical Care at University Hospital Galway began to tackle the educational challenge by developing an  in situ interprofessional simulation programme to prepare staff for the impending outbreak. Principles and approaches used for simulation-based training: We describe principles applied to identify core educational and system engineering objectives to prepare healthcare workers (HCWs) for infection control, personal and psychological safety, technical and crisis resource management skills. We discuss application of educational theories, rationale for simulation modes and debriefing techniques. Development of the simulation programme: 3 anaesthesia (general, obstetric, paediatric) and 1 critical care silo were created. 13 simulated scenarios were developed for teaching as well as for testing workflows specific to the outbreak. To support HCWs and ensure safety, management guidelines, cognitive aids and checklists were developed using simulation. The cumulative number of HCWs trained in simulation was 750 over a 4-week period. Challenges and future directions: Due to the protracted nature of the pandemic, simulation educators should address questions related to sustainability, infection control while delivering simulation, establishment of hybrid programmes and support for psychological preparedness.

Retinoblastoma: Early Diagnosis is Crucial.

Retinoblastoma is an uncommon solid tumor diagnosed in infants and toddlers. This cancer has a 95% survival rate when diagnosed early. However, this tumor can cause low vision, blindness or loss of life, if not diagnosed early. Pediatric primary care providers are instrumental in detecting abnormal vision findings because they can perform a thorough history and eye examination needed for early detection.

How advanced practice registered nurse practice barriers impact health care access in Michigan.

ABSTRACT: Despite the Affordable Care Act increasing the number of insured individuals in Michigan, many individuals cannot access care as the state continues to have a provider shortage that is likely to get worse. It is well documented that when individuals lack primary care access, their health suffers. Advanced practice registered nurses (APRN) could help reduce the state's health care shortage, as the care they provide is safe, cost effective, and high quality. Unfortunately, Michigan's APRN practice restrictions limit these professionals from autonomously providing care to the underserved and rural populations that need them the most. Indeed, Michigan is behind other states that offer full practice authority to APRNs, and its health outcomes reflect this stance. Eliminating the restrictive practice environment in Michigan will give citizens better access to primary care.