Insulin Glargine Associated Nausea in a Patient Seen by a Collaborative Drug Therapy Management Pharmacist in an Urban Community Hospital: A Case Report.

Background: Diabetes mellitus has become increasingly prevalent and a considerable health risk in the United States. Early introduction of insulin can improve overall health outcomes of patients with diabetes. With the development of long-acting insulin analogs, such as insulin glargine, limitations such as variable absorption and hypoglycemia were reduced. Majority of reported adverse drug effects secondary to insulin glargine include injection site reaction and hypoglycemia. There is limited data on gastrointestinal adverse effects, including nausea, of insulin glargine. Case Presentation: A 51-year-old female with a past medical history of type 2 diabetes was referred to the collaborative drug therapy management pharmacist for diabetes education and management. The patient was initiated on insulin glargine (Lantus®) and began to experience episodes of nausea and emesis over a 9 week period. Once the patient was switched from insulin glargine (Lantus®) to insulin detemir, symptoms subsided. Upon re-trial of insulin glargine (Lantus®), nausea and emesis-like symptoms resumed. A probable relationship between insulin glargine (Lantus®) and the reaction was estimated using the Naranjo Adverse Drug Reaction Probability Scale. Conclusion: Potential mechanisms behind the relationship of insulin glargine (Lantus®) and nausea are hypothesized, however there is limited literature supporting this claim and further investigation is warranted.

Effectiveness and acceptability of intranasal povidone-iodine decolonization among fracture fixation surgery patients to reduce Staphylococcus aureus nasal colonization.

We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL (P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.

Extracorporeal Membrane Oxygenation Support for Antineutrophil Cytoplasmic Antibody-associated Vasculitides: An ELSO Registry Analysis.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides with pulmonary involvement include granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, and can present with life-threatening pulmonary hemorrhage in up to 40% of patients. Mortality in those patients who require intubation and mechanical ventilation can reach 77%. Extracorporeal membrane oxygenation (ECMO) can be used to support these patients through definitive diagnosis and treatment, although minimizing the risk of ventilator-induced lung injury. We aimed to determine factors associated with favorable outcomes in patients with (ANCA)-associated vasculitides supported on ECMO. We performed a retrospective observational study using the Extracorporeal Life Support Organization registry of pediatric and adult patients with ANCA-associated vasculitis supported on ECMO from 2010 to 2020. One hundred thirty-five patients were included for analysis. Many patients had renal involvement (39%) in addition to pulmonary involvement (93%). Survival was 73% in AAV patients supported on ECMO. The presence of pulmonary hemorrhage was not associated with worse outcomes in our cohort. Older age, the use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, or sustaining a cardiac arrest before ECMO was associated with decreased survival. In conclusion, venovenous ECMO should be considered as a supportive bridge to definitive diagnosis and treatment in (ANCA)-associated vasculitides, regardless if pulmonary hemorrhage is present.

Are body dysmorphic symptoms dimensional or categorical in nature? A taxometric investigation in adolescents.

Body dysmorphic disorder (BDD) is a debilitating mental health condition which usually emerges during adolescence and is characterised by distressing and impairing appearance concerns. It is currently unclear whether body dysmorphic concerns represent an extreme manifestation of normal appearance concerns (a dimensional conceptualisation), or whether they are qualitatively distinct (a categorical conceptualisation). This study aimed to determine whether body dysmorphic symptoms are dimensional or categorical in nature by investigating the latent structure using taxometric procedures. Body dysmorphic symptoms were assessed using validated measures among 11-16-year-old school pupils (N=707). Items of the Body Image Questionnaire Child and Adolescent version were used to construct four indicators that broadly corresponded to the DSM-5 diagnostic criteria for BDD (appearance concerns, repetitive behaviours, impairment, and insight). Indicators were submitted to three non-redundant taxometric procedures (MAMBAC, MAXEIG and L-MODE). Overall, results of all three taxometric procedures indicated a dimensional latent structure of body dysmorphic symptoms. The current study provides preliminary evidence that body dysmorphic symptoms are continuously distributed among adolescents, with no evidence of qualitative differences between mild and severe symptoms. Implications for clinical practice and research are discussed.

Mass food challenges in a vacant COVID-19 stepdown facility: Exceptional opportunity provides a model for the future.

BACKGROUND: Internationally, the COVID-19 pandemic severely curtailed access to hospital facilities for those awaiting elective/semi-elective procedures. For allergic children in Ireland, already waiting up to 4 years for an elective oral food challenge (OFC), the restrictions signified indefinite delay. At the time of the initiative, there were approx 900 children on the Children's Health Ireland (CHI) waiting list. In July 2020, a project was facilitated by short-term (6 weeks) access to an empty COVID stepdown facility built, in a hotel conference centre, commandeered by the Health Service Executive (HSE), Ireland. The aim of this study was to achieve the rapid roll-out of an offsite OFC service, delivering high throughput of long waiting patients, while aligning with existing hospital policies and quality standards, international allergy guidelines and national social distancing standards. METHODS: The working group engaged key stakeholders to rapidly develop an offsite OFC facility. Consultant paediatric allergists, consultant paediatricians, trainees and allergy clinical nurse specialists were seconded from other duties. The facility was already equipped with hospital beds, bedside monitors (BP, pulse and oxygen saturation) and bedside oxygen. All medication and supplies had to be brought from the base hospital. Daily onsite consultant anaesthetic cover was resourced and a resuscitation room equipped. Standardized food challenge protocols were created. Access to the onsite hotel chef facilitated food preparation. A risk register was established. RESULTS: After 6 weeks of planning, the remote centre became operational on 7/9/2020, with the capacity of 27 OFC/day. 474 challenges were commenced: 465 (98%) were completed and 9 (2%) were inconclusive. 135 (29%) OFCs were positive, with 25 (5%) causing anaphylaxis. No child required advanced airway intervention. 8 children were transferred to the base hospital. The CHI allergy waiting list was reduced by almost 60% in only 24 days. CONCLUSIONS: Oral food challenges remain a vital tool in the care of allergic children, with their cost saving and quality-of-life benefits negatively affected by a delay in their delivery. This project has shown it is possible to have huge impacts on a waiting list efficiently, effectively and safely with good planning and staff buy-in-even in a pandemic. Adoption of new, flexible and efficient models of service delivery will be important for healthcare delivery in the post-COVID-19 era.

Motion-corrected cardiac MRI is associated with decreased anesthesia exposure in children.

BACKGROUND: The benefits of cardiac magnetic resonance imaging (MRI) in the pediatric population must be balanced with the risk and cost of anesthesia. Segmented imaging using multiple averages attempts to avoid breath-holds requiring general anesthesia; however, cardiorespiratory artifacts and prolonged scan times limit its use. Thus, breath-held imaging with general anesthesia is used in many pediatric centers. The advent of free-breathing, motion-corrected (MOCO) cines by real-time re-binned reconstruction offers reduced anesthesia exposure without compromising image quality. OBJECTIVE: This study evaluates sedation utilization in our pediatric cardiac MR practice before and after clinical introduction of free-breathing MOCO imaging for cine and late gadolinium enhancement. MATERIALS AND METHODS: In a retrospective study, patients referred for a clinical cardiac MR who would typically be offered sedation for their scan (n=295) were identified and divided into two eras, those scanned before the introduction of MOCO cine and late gadolinium enhancement sequences and those scanned following their introduction. Anesthesia use was compared across eras and disease-specific cohorts. RESULTS: The incidence of non-sedation studies performed in children nearly tripled following the introduction of MOCO imaging (25% [pre-MOCO] to 69% [post-MOCO], P<0.01), with the greatest effect in patients with simple congenital heart disease. Eleven percent of the post-MOCO cohort comprised infants younger than 3 months of age who could forgo sedation with the combination of MOCO imaging and a "feed-and-bundle" positioning technique. CONCLUSION: Implementation of cardiac MR with MOCO cine and late gadolinium enhancement imaging in a pediatric population is associated with significantly decreased sedation utilization.

Is perfectionism a risk factor for adolescent body dysmorphic symptoms? Evidence for a prospective association.

The current study tested the hypothesis that perfectionism is a risk factor for the development of body dysmorphic disorder (BDD), as proposed by prevailing cognitive behavioural models. School students aged 14-16 years completed questionnaires 6 months apart (Time 1: N = 302; Time 2: N = 68) assessing perfectionism, BDD symptoms, and anxiety and depression. Robust regression models tested concurrent and prospective associations between perfectionism and BDD symptoms, with and without adjustment for coexisting anxiety and depression. Total perfectionism was positively associated with concurrent BDD symptoms, even when controlling for coexisting anxiety and depression. Moreover, total perfectionism predicted changes in BDD symptoms between Time 1 and Time 2. Examination of perfectionism subscales indicated that only self-oriented perfectionism, not socially-prescribed perfectionism, predicted BDD symptoms concurrently and prospectively while controlling for coexisting psychopathology. This study provides preliminary evidence for self-oriented perfectionism being a risk factor for the development of BDD in youth. If replicated, these findings could highlight the potential value of targeting self-oriented perfectionism in prevention and early intervention programs for BDD.

Pharmacist-Driven Step-Down of Long-Term Proton-Pump Inhibitor Therapy.

OBJECTIVE: To evaluate the appropriateness of proton-pump inhibitor (PPI) prescribing and reduce the number of outpatients on long-term PPI therapy, defined as greater than or equal to one year.
DESIGN: Phase I was retrospective and evaluated the appropriateness of PPI prescribing. Phase II was prospective and involved implementation of a pharmacist-driven PPI step-down protocol.
SETTING: This study was conducted in an outpatient setting at Veterans Affairs Hudson Valley Health Care System.
PATIENTS, PARTICIPANTS: Patients were limited to a single primary care provider and were required to fill an outpatient PPI prescription between August 15, 2015, and August 15, 2016.
INTERVENTIONS: After patients were identified in Phase I as having an inappropriate indication for long-term PPI therapy, they were contacted by a pharmacist to complete the step-down protocol. The patients then received a call two weeks after completing each step.
MAIN OUTCOME MEASURE(S): To determine the number of patients without an indication for long-term PPI therapy that could successfully complete the PPI step-down protocol.
RESULTS: Phase I identified that long-term PPI therapy was not indicated in 68.4% of patients. Phase II implementation demonstrated that 71.4% of patients were able to successfully step-down from PPI therapy in an average of 13 weeks with the use of alternative acid-suppression therapy.
CONCLUSION: This study concluded that a majority of PPI prescriptions were not indicated for a duration of greater than or equal to 1 year. With the implementation of a pharmacist-driven PPI step-down protocol, a majority of patients were able to tolerate the PPI step-down with the use of alternative acidsuppression therapy.

Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study.

Purpose: This study aimed to determine the feasibility of delivering a group speech maintenance programme (eLoud and Proud) to people with Parkinson's disease via telerehabilitation. Method: Treatment was delivered to eight participants who had previously received LSVT LOUD®. The programme focussed on using a "loud" voice within conversational and cognitively loaded tasks, and was delivered in two 90-minute sessions per week for four weeks. Data pertaining to sound pressure level (SPL) (for sustained phonation, reading and monologue tasks), maximum frequency range, maximum phonation duration and impact of dysarthria on quality of life were collected at three time points: (1) pre-treatment (PRE); (2) immediately post-treatment (POST); and (3) three months post-treatment (FU). Participant satisfaction with telerehabilitation was also obtained at POST. Result: Significant improvements were identified for all SPL measures PRE-POST and maintained for sustained phonation and reading tasks at FU. No significant differences were identified for the remaining outcome measures. Participants were overall highly satisfied with telerehabilitation and considered it to be an acceptable alternative to traditional service delivery. Conclusion: This study demonstrated the feasibility of delivering group speech maintenance therapy via telerehabilitation, and the potential for eLoud and Proud to improve and maintain vocal loudness in people with PD.

Computational Investigation of a Self-Powered Fontan Circulation.

Children born with anatomic or functional "single ventricle" must progress through two or more major operations to sustain life. This management sequence culminates in the total cavopulmonary connection, or "Fontan" operation. A consequence of the "Fontan circulation", however, is elevated central venous pressure and inadequate ventricular preload, which contribute to continued morbidity. We propose a solution to these problems by increasing pulmonary blood flow using an "injection jet" (IJS) in which the source of blood flow and energy is the ventricle itself. The IJS has the unique property of lowering venous pressure while enhancing pulmonary blood flow and ventricular preload. We report preliminary results of an analysis of this circulation using a tightly-coupled, multi-scale computational fluid dynamics model. Our calculations show that, constraining the excess volume load to the ventricle at 50% (pulmonary to systemic flow ratio of 1.5), an optimally configured IJS can lower venous pressure by 3 mmHg while increasing systemic oxygen delivery. Even this small decrease in venous pressure may have substantial clinical impact on the Fontan patient. These findings support the potential for a straightforward surgical modification to decrease venous pressure, and perhaps improve clinical outcome in selected patients.

Men with Anterior Urethral Strictures are Often Treated without Imaging or Discussion of all Treatment Options.

INTRODUCTION: We determined how men presenting to our institution with anterior urethral strictures and recurrent strictures after treatment were evaluated, counseled and treated. METHODS: A prospective study was performed of all patients presenting to our institution with recurrent anterior urethral stricture disease between 2011 and 2014. Outside records were reviewed and all patients were queried to determine if they had any urethral imaging before treatment, what treatment was given and what other options were discussed. Patients were excluded from the study if they had a history of hypospadias, or if they were initially treated more than 10 years ago or treated outside of the United States. RESULTS: A total of 100 men were included in the study, of whom 89 (89%) had prior treatment with urethral dilation or endoscopic incision. Of these patients 81 (91%) were treated without prior urethral imaging. Of the 90 patients who were treated or advised to have treatment with direct visual internal urethrotomy or dilation, 81 (90%) were not offered urethroplasty as an option. There were 66 patients who had multiple such treatments and of this group only 6 (9%) were offered urethroplasty before subsequent treatment. CONCLUSIONS: In this study the majority of men with urethral strictures were treated without urethral imaging. Furthermore, most men were not offered urethroplasty as an option before undergoing 1 or more urethral dilations or internal urethrotomies.

Tumor necrosis factor receptor 2 (TNFR2) signaling is negatively regulated by a novel, carboxyl-terminal TNFR-associated factor 2 (TRAF2)-binding site.

Tumor necrosis factor (TNF) superfamily receptors typically induce both NF-kappaB and JNK activation by recruiting the TRAF2 signal transduction protein to their cytoplasmic domain. The type 2 TNF receptor (TNFR2), however, is a poor activator of these signaling pathways despite its high TRAF2 binding capability. This apparent paradox is resolved here by the demonstration that TNFR2 carries a novel carboxyl-terminal TRAF2-binding site (T2bs-C) that prevents the delivery of activation signals from its conventional TRAF2-binding site (T2bs-N). T2bs-C does not conform to canonical TRAF2 binding motifs and appears to bind TRAF2 indirectly via an as yet unidentified intermediary. Specific inactivation of T2bs-N by site-directed mutagenesis eliminated most of the TRAF2 recruited to the TNFR2 cytoplasmic domain but had no effect on ligand-dependent activation of the NF-kappaB or JNK pathways. By contrast, inactivation of T2bs-C had little effect on the amount of TRAF2 recruited but greatly enhanced ligand-dependent NF-kappaB and JNK activation. In wild-type TNFR2 therefore, T2bs-C acts in a dominant fashion to attenuate signaling by the intrinsically more active T2bs-N but not by preventing TRAF2 recruitment. This unique uncoupling of TRAF2 recruitment and signaling at T2bs-N may be important in the modulation by TNFR2 of signaling through coexpressed TNFR1.

Low recognition of childhood overweight and disease risk among Native-American caregivers.

OBJECTIVES: Pediatric obesity is a significant and increasing problem in Native-American communities. The aim of this study was to determine whether parents and other caregivers from three Wisconsin tribes recognized overweight children. We also assessed caregiver attributes associated with levels of concern for risk of future overweight and chronic disease. RESEARCH METHODS AND PROCEDURES: Data were obtained from child health screenings and caregiver surveys. Participants included 366 kindergarten-through-second grade child-caregiver dyads. Children's BMI percentiles were calculated and compared with caregiver responses. We assessed the relationships between predictors of caregiver concern for health risk factors and recognition of overweight. RESULTS: Twenty-six percent of children were overweight (>or=95th percentile), and 19% were at risk for being overweight (>or=85th to <95th percentile) using Centers for Disease Control standards. Caregivers recognized only 15.1% of overweight children. Factors predictive of child overweight recognition included a child BMI >99th percentile and grandmother as caregiver. Overall, caregivers were more concerned about diabetes and cardiovascular disease than obesity. Parents with diabetes and heart disease were more concerned than others about risk for these diseases; however, only diabetic parents made a connection between child weight status and future risk of obesity-related disease. Child sex, child age, and parental education level were not significant predictors for caregiver recognition of an overweight child. DISCUSSION: Most caregivers did not recognize overweight children or associate excess weight with increased risk of disease. When designing community interventions, it is crucial to incorporate caregivers' attitudes and beliefs regarding childhood overweight and risk of future disease.

Relative measures of geographic range size: empirical comparisons.

Many different measures of range size are used for both empirical and conservation purposes. The possible consequences of the particular methods used in determining observed patterns of results are seldom considered. Using species of butterflies and freshwater molluses in Britain, we investigate the relationship between the range sizes measured by nine different methods and the sets of rare species they distinguish. A comparison of range sizes measured at different scales. Britain and Europe, is also made for the butterflies. We find that for many studies involving range size the various measures of range size are interchangeable. With respect to the identification of rare species the results are not as clear.