Loperamide Misuse Mimicking Symptoms of Severe Malnutrition.

Loperamide, an oral over-the-counter µ-opioid receptor agonist used to treat diarrhea, acts primarily in the gut and, when used as recommended, has little to no systemic effect. At high doses, it may cause a "high" like other opioids. Recent literature describes an increasing incidence of loperamide misuse and overdose in the setting of the US opioid epidemic. In this case, we describe a 16-year-old with anorexia nervosa who developed dizziness, syncope, and constipation at the time of weight loss. These symptoms were originally attributed to malnutrition; however, after weight restoration, her symptoms worsened. She did not respond to initial management of suspected postural orthostatic tachycardia syndrome (POTS). She then developed acute urinary retention requiring hospitalization. Her symptoms were ultimately found to be caused by chronic surreptitious high-dose loperamide use. Her symptoms rapidly improved after cessation. This case illustrates the non-specific symptoms associated with loperamide misuse and the potential overlap with other common adolescent conditions. Adolescent medicine clinicians must be aware of the signs and symptoms of loperamide misuse as well as familiar with recommendations for both the management of acute complications and the treatment of the substance misuse.

Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Emerging data suggest the coronavirus disease 2019 (COVID-19) pandemic has been associated with worsening symptoms of eating disorders (EDs) among both adults and adolescents. With this study, we sought to determine if medical admission patterns among adolescents admitted to our institution for restrictive EDs changed during the pandemic, relative to prepandemic counts of admissions per month. METHODS: We performed a chart review of patients aged 10 to 23 years admitted to our children's hospital for restrictive EDs from March 2017 through March 2021 and completed an interrupted time series analysis of admission counts per month. Demographic variables for admitted patients were compared by using χ2, Fisher's exact, and 2-sample t tests. RESULTS: ED-related medical admissions at our institution increased significantly during the COVID-19 pandemic. The total number of admissions during the first 12 months of the COVID-19 pandemic (April 1, 2020, through March 31, 2021, n = 125) was more than double the mean number of admissions per year for the same time frame (April 1 through March 31) for the previous 3 years (mean = 56). Patient demographics were similar before and during the pandemic, with the exception that patients admitted during the COVID-19 pandemic were less likely than those admitted before the pandemic to have public insurance. CONCLUSIONS: Medical admissions related to restrictive EDs among adolescents increased significantly during the COVID-19 pandemic. Pediatric providers in a variety of settings should be prepared to care for adolescents with restrictive EDs during the pandemic.

Study of baseline radon levels in the context of a shale gas development.

This study reports the results from continuous measurement of indoor and outdoor radon concentrations in the area surrounding an unconventional shale gas exploration site in North Yorkshire, England, prior to the commencement of hydraulic fracturing. Public Health England has monitored the baseline radon levels in homes and in outdoor air in the Vale of Pickering since 2015. The statistical analysis presented here includes three full years (November 2015- -December 2018) of indoor and four and half years (October 2015 - April 2019) of outdoor radon measurements. Stratified sampling was used to select 171 dwellings in four areas, with two different radon potential. Statistical analysis confirms that homes in Kirby Misperton and Little Barugh and those in Yedingham are situated in areas with low radon potential, as was predicted by the UK radon potential map. On the other hand, both Pickering and Malton are confirmed as radon Affected Areas. Radon was measured continuously in the outdoor air using a newly developed outdoor kit containing passive radon detectors. The monitoring points were set up at 36 locations in the same local areas as those selected for the indoor monitoring. The results from statistical analysis show that outdoor radon had a different seasonality pattern to indoor radon. The monitoring of outdoor radon levels over the four and half years indicates a year-to-year variation in outdoor radon concentrations with levels fluctuating between 3 and 9 Bq m-3. There was a very good agreement between long-term average radon concentrations measured using passive detectors and using an active AlphaGUARD monitor.

The Speech "Bamana": Using the Syllable Repetition Task to Identify Underlying Phonological Deficits in Children With Speech and Language Impairments.

Purpose This study compared performance on the Syllable Repetition Task (SRT) by preschoolers with diverse speech and language abilities to identify underlying impairments in speech processes. Method Three groups of 13 children ages 4 and 5 years with (a) typically developing (TD) speech and language, (b) speech sound disorder (SSD), and (c) comorbid developmental language disorder and speech sound disorder (DLD + SSD) completed the SRT. We calculated competence, memory, encoding, and transcoding scores, as well as word-initial stress pattern and vowel accuracy. Results A 3 × 3 (Group × Syllable length) factorial multivariate analysis of covariance revealed group differences for all measures and syllable length differences for memory, transcoding, and competence. There were no interactions between group and syllable length. TD children obtained the highest scores on each measure, though children with DLD + SSD performed similarly to TD children on encoding when vocabulary was included as a covariate. Children with SSD only outperformed children with DLD + SSD on competence and transcoding, and these two groups performed similarly on memory. A separate exploratory analysis using a 3 × 3 multivariate analysis of covariance revealed that children with DLD + SSD were more likely than children in the other groups to produce weak word-initial stress and vowel errors during syllable repetition. Conclusion Children with SSD and DLD + SSD exhibit underlying phonological deficits on the SRT compared to TD children. Results support the claim that memory and encoding are deficits in SSD. In addition, transcoding deficits were identified among children with no known oromotor impairment. Therefore, more research is required to identify the relationship between SRT performance and explicit measures of phonological processing.

Use of Intraoperative CO2 Laser for the Resection of a Ventral Intradural Extramedullary Cervical Spinal Tumor: 2-Dimensional Operative Video.

Ventral spinal tumors are surgically challenging because the tumor resection should minimize spinal cord and nerve root manipulation to minimize morbidity, while providing access to a complete tumor resection. The CO2 laser has been useful in resection of central nervous system tumors, but little is described about the method used to resect spinal tumors.1 This video demonstrates the removal of a ventral cervical spinal meningioma using the CO2 laser. A 62-yr-old man presented with progressive paresthesias, gait instability, and urinary frequency. A 1-cm intradural extramedullary mass at C5 showed severe spinal cord compression. Patient consent was obtained prior to performing the procedure. A posterior lateral approach is shown, with a bone removal corridor created at C5 for accessing the tumor ventrally. A right-sided facetectomy and pediculectomy at C5 were performed being flush with the posterior vertebral body. A dural opening positioned laterally provided a working corridor between C5 and C6 nerve rootlets. Lateral portions of tumor were excised in wedge-shaped slices starting laterally and working medially. These slices created a successive and enlarging space to safely allow piecemeal tumor dissection and removal, while limiting retraction upon the spinal cord. The CO2 laser was used to cauterize the tumor capsule, create wedge resections of tumor, and coagulate the final dural attachment. The pathology was a meningioma WHO Grade I. The patient did well, with resolution of parasthesias and ataxia. The CO2 laser technique allowed for limited spinal cord retraction throughout the tumor resection and gross total resection of the tumor was achieved.

Rethinking the Admissions Interview: Piloting Multiple Mini-Interviews in a Graduate Psychology Program.

Health profession programs routinely utilize traditional interviews in admissions as a means of assessing important non-academic characteristics (e.g., critical thinking, interpersonal skills, judgment) of candidates. However, the reliability and validity of traditional interviews is highly questionable. Given this, multiple health profession programs (e.g., medicine, nursing, pharmacy, physical therapy) have implemented multiple mini-interviews as an alternative for assessing non-academic characteristics. This paper describes the development and implementation of multiple mini-interviews in the admissions process for a doctoral clinical psychology program, one of the health professions yet to use multiple mini-interviews. This paper also examines the feasibility and acceptability of the multiple mini-interviews in this program. Results of a mixed-method survey of all 120 candidates who participated in admissions days are presented along with discussion of factors associated with satisfaction and dissatisfaction. Recommendations for program refinement and application to other graduate psychology programs for improved admissions processes are discussed.

A novel technique for awake, minimally invasive transforaminal lumbar interbody fusion: technical note.

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is associated with improved patient-reported outcomes in well-selected patients. Recently, some neurosurgeons have aimed to further improve outcomes by utilizing multimodal methods to avoid the use of general anesthesia. Here, the authors report on the use of a novel awake technique for MI-TLIF in two patients. They describe the successful use of liposomal bupivacaine in combination with a spinal anesthetic to allow for operative analgesia.

Chlorhexidine Showers are Associated With a Reduction in Surgical Site Infection Following Spine Surgery: An Analysis of 4266 Consecutive Surgeries.

BACKGROUND: Surgical site infection (SSI) is a common complication following spinal surgery. Prevention is critical to maintaining safe patient care and reducing additional costs associated with treatment. OBJECTIVE: To determine the efficacy of preoperative chlorhexidine (CHG) showers on SSI rates following fusion and nonfusion spine surgery. METHODS: A mandatory preoperative CHG shower protocol was implemented at our institution in November 2013. A cohort comparison of 4266 consecutive patients assessed differences in SSI rates for the pre- and postimplementation periods. Subgroup analysis was performed on the type of spinal surgery (eg, fusion vs nonfusion). Data represent all spine surgeries performed between April 2012 and April 2016. RESULTS: The overall mean SSI rate was 0.4%. There was no significant difference between the pre- (0.7%) and postimplementation periods (0.2%; P = .08). Subgroup analysis stratified by procedure type showed that the SSI rate for the nonfusion patients was significantly lower in the post- (0.1%) than the preimplementation group (0.7%; P = .02). There was no significant difference between SSI rates for the pre- (0.8%) and postimplementation groups (0.3%) for the fusion cohort (P = .21). In multivariate analysis, the implementation of preoperative CHG showers were associated with significantly decreased odds of SSI (odds ratio = 0.15, 95% confidence interval [0.03-0.55], P < .01). CONCLUSION: This is the largest study investigating the efficacy of preoperative CHG showers on SSI following spinal surgery. In adjusted multivariate analysis, CHG showering was associated with a significant decrease in SSI following spinal surgery.

Surgical management of camptocormia in Parkinson's disease: systematic review and meta-analysis.

OBJECTIVE: Camptocormia is a potentially debilitating condition in the progression of Parkinson's disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia. METHODS: PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis. RESULTS: The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15). CONCLUSIONS: Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.

Evolution of the Minimally Invasive Spinal Deformity Surgery Algorithm: An Evidence-Based Approach to Surgical Strategies for Deformity Correction.

Minimally invasive surgery (MIS) is an alternative to open surgery for adult spinal deformity correction. However, not all patients are ideal candidates for MIS correction. The minimally invasive spinal deformity surgery algorithm is a systematic and reproducible decision-making framework for surgeons to identify patients appropriate for deformity correction by MIS techniques. Key spinopelvic parameters including sagittal vertical axis, pelvic tilt, pelvic incidence to lumbar lordosis mismatch, and coronal Cobb angle are used to guide surgeons toward three treatment classes ranging from MIS to traditional open approaches. This article updates the minimally invasive spinal deformity surgery algorithm and presents representative cases.

Navigation-Assisted Minimally Invasive Surgery Deformity Correction.

Surgical correction of deformity is a complex endeavor. Although more traditional, open techniques remain important, minimally invasive surgery (MIS) techniques have been increasingly studied as an alternative approach. In particular, the circumferential MIS approach, which may incorporate a lateral/anterior as well as a subsequent posterior approach, has been investigated as a promising algorithm/protocol. Utilization of navigation guidance during MIS deformity correction is an important intraoperative tool for the surgeon.

Cell growth of immortalized arachnoid cells in the presence of fibroblasts and blood products.

OBJECT: The pathophysiology of non-obstructive hydrocephalus involves alteration in cerebrospinal fluid (CSF) pathways. The exact mechanism is unknown, but as arachnoid CSF egress is a major route of CSF removal, damage or alteration to the growth of arachnoid cells may influence the rate of CSF absorption. We investigated the effect of soluble factors secreted by fibroblasts and the presence of blood products on arachnoid cell growth. METHODS: An immortalized arachnoid cell line was developed and cells were grown on semipermeable membranes in a culture chamber. Arachnoid cells were plated in Transwells®, with fibroblasts separated from the arachnoid cells. Cell phenotype was analyzed and cell growth rates were determined by manual counts. Similar experiments were conducted with biliverdin, bilirubin, as well as fibroblast challenge. DNA content in the cell cultures was then determined as corroborative data. Cell counts for the additional arachnoid cell lines were calculated at each day and represented the controls. RESULTS: Cell counts increased with each time point. Arachnoid cells in the three experimental conditions showed a statistically significant decrease in cell counts for each day when compared to the control group. Post hoc analysis showed differences between the control and experimental conditions but no significant difference between groups. The DNA content for each experimental condition was reduced at all time points when compared to the control arachnoid cells, but only became statistically significant at day 7. CONCLUSION: Inflammation and hemorrhage are two common conditions associated with the development of hydrocephalus. The arachnoid membrane is exposed to fibroblasts and blood products (bilirubin, biliverdin) in these conditions, and their effect on arachnoid cell growth was studied. We have shown that arachnoid cell growth decreases in the presence of fibroblasts, bilirubin, and biliverdin. Given its intimate relationship with CSF, it is possible that the decreased growth of arachnoid cells may affect absorption and thus contribute to the development of hydrocephalus.

Reliability of the Planned Pedicle Screw Trajectory versus the Actual Pedicle Screw Trajectory using Intra-operative 3D CT and Image Guidance.

BACKGROUND: Technological advances, including navigation, have been made to improve safety and accuracy of pedicle screw fixation. We evaluated the accuracy of the virtual screw placement (Stealth projection) compared to actual screw placement (intra-operative O-Arm) and examined for differences based on the distance from the reference frame. METHODS: A retrospective evaluation of prospectively collected data was conducted from January 2013 to September 2013. We evaluated thoracic and lumbosacral pedicle screws placed using intraoperative O-arm and Stealth navigation by obtaining virtual screw projections and intraoperative O-arm images after screw placement. The screw trajectory angle to the midsagittal line and superior endplate was compared in the axial and sagittal views, respectively. Percent error and paired t-test statistics were then performed. RESULTS: Thirty-one patients with 240 pedicle screws were analyzed. The mean angular difference between the virtual and actual image in all screws was 2.17° ± 2.20° on axial images and 2.16° ± 2.24° on sagittal images. There was excellent agreement between actual and virtual pedicle screw trajectories in the axial and sagittal plane with ICC = 0.99 (95%CI: 0.992-0.995) (p<0.001) and ICC= 0.81 (95%CI: 0.759-0.855) (p<0.001) respectively. When comparing thoracic and lumbar screws, there was a significant difference in the sagittal angulation between the two distributions. No statistical differences were found distance from the reference frame. CONCLUSION: The virtual projection view is clinically accurate compared to the actual placement on intra-operative CT in both the axial and sagittal views. There is slight imprecision (~2°) in the axial and sagittal planes and a minor difference in the sagittal thoracic and lumbar angulation, although these did not affect clinical outcomes. In general, we find that pedicle screw placement using intraoperative cone beam CT and navigation to be accurate and reliable, and as such have made it a routine part of our spine practice. This study was approved by the University of Minnesota IRB (#1303E30544).

Michel Hersen and the administration of professional psychology programs.

From 1997 until his retirement in 2011, Michel Hersen served as the dean of the School of Professional Psychology (SPP) at Pacific University in Oregon. Through teaching, supervision, and modeling, Michel promoted his vision of a professional school that could compete on the national stage. He grew the program from a regional focus to one with a strong national presence through careful faculty hires and by anticipating national trends in diversity issues and interprofessional education. His decisions as an administrator were sometimes counterintuitive and challenged the status quo, but they often were correct and advanced the program. His footprint as an administrator was quite large and will be difficult to fill. The SPP benefited greatly from his leadership, and it will continue to grow by following the plans he set in place for us.

An introduction to eating disorders: clinical presentation, epidemiology, and prognosis.

The spectrum of eating disorders varies widely, ranging from mildly abnormal eating habits to life-threatening chronic disease. Given the many different cultural food norms and individual preferences, along with the fact that dieting behavior is extremely common, it can be challenging to differentiate unusual eating behaviors from clinically significant eating disorders. In this article, the authors provide an introduction to eating disorders including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, focusing on the clinical presentation, epidemiology, and prognosis.

Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication.

OBJECTIVE: To examine the association between adolescents' perception of clinician communication and adolescents' reported acceptability of the steps involved in chlamydial screening during urgent care visits. DESIGN: Cross-sectional survey of adolescents after urgent care visits. SETTING: Four pediatric clinics in a health maintenance organization. PARTICIPANTS: Three hundred sixty-five adolescents aged 13 to 18 years. OUTCOME MEASURES: Participants' ratings of the acceptability of talking about sexual health and providing a urine sample for chlamydial testing in an urgent care visit. RESULTS: Most adolescents found sexual health discussions and urine collection for chlamydial screening acceptable in the urgent care setting (84% and 80%, respectively). Acceptability of sexual health discussion was significantly associated with adolescents' perception that the clinician explained confidentiality (adjusted odds ratio [AOR], 2.7; 95% confidence interval [CI], 1.3-5.5), knew "how to talk to teens like me" (AOR, 9.0; 95% CI, 3.5-24.2), and "listened carefully as I explained my concerns" (AOR, 14.3; 95% CI, 4.3-54.9). Acceptability of providing a urine sample for chlamydial testing was associated with the adolescents' perception that the clinician knew "how to talk to teens like me" (AOR, 3.7; 95% CI, 1.5-9.3) and "listened carefully as I explained my concerns" (AOR, 3.6; 95% CI, 1.1-11.5). CONCLUSIONS: Sexual history taking and urine collection are 2 key components of chlamydial screening and were reported as acceptable by the great majority of adolescents in the urgent care setting. Aspects of clinician communication appear to be important target areas for pediatric clinician education in supporting expansion of chlamydial screening to adolescents in urgent care visits.

Shifted, the Drosophila ortholog of Wnt inhibitory factor-1, controls the distribution and movement of Hedgehog.

We here identify and characterize an extracellular modulator of Hedgehog signaling in Drosophila, Shifted. Shifted is required for high levels of long-range signaling in the developing wing imaginal disc. Surprisingly, shifted encodes the only Drosophila ortholog of the secreted vertebrate protein Wnt Inhibitory Factor-1 (WIF-1), whose known role is to bind to extracellular Wnts and inhibit their activity. However, Shifted does not regulate Hedgehog signaling by affecting Wingless or Wnt signaling. We show instead that Shifted is a secreted protein that acts over a long distance and is required for the normal accumulation of Hh protein and its movement in the wing. Our data further indicate that Shf interacts with Hh and the heparan sulfate proteoglycans. Therefore, we propose that Shf stabilizes the interaction between Hh and the proteoglycans, an unexpected role for a member of the WIF-1 family.