MITRAL REGURGITATION IN SADDLE-BILLED STORKS (EPHIPPIORHYNCHUS SENEGALENSIS) IN HUMAN CARE: DIAGNOSIS, ECHOCARDIOGRAPHIC MEASUREMENTS, AND MANAGEMENT.

The asymptomatic and slow progressive nature of cardiopathies represents a risk to the welfare of avian species in human care. Diagnosis and treatment of cardiac disease in birds pose a challenge due to unique anatomic and physiologic characteristics. Comprehensive cardiac assessments with diagnostic tools such as echocardiography, color-Doppler, the biomarker cardiac troponin I (cTn1), and cholesterol serum concentrations have been utilized in different bird species with varying success. Saddle-billed storks (Ephippiorhynchus senegalensis) have been maintained in human care for over 80 yrs and several institutions have noted heart murmurs and cardiomegaly. Despite these findings, peer-reviewed literature describing cardiopathies is lacking for this species. This case series documents the identification of mitral valve regurgitation in saddle-billed storks in a breeding center. Transcoelomic echocardiography using a ventromedial approach with a two-chambered view and color Doppler was utilized. Echocardiographic measurements were taken and compared 1 yr later in most of the birds. There was left atrial enlargement and worsened mitral regurgitation in one geriatric patient, and no progression of the disease in two young birds. Serum samples showed that cTn1 had different concentrations depending on the severity of the disease, whereas cholesterol was within reference range for all birds. Treatment with digoxin and pimobendan was recommended in one bird, serum concentrations of digoxin were tested in a 6-mon span, results were within therapeutic range, and there were no overt adverse effects. There was a suspected genetic component in this population, as four of the five birds with confirmed mitral regurgitation were related.

Longitudinal intraocular pressure measurements in Whooping cranes (Grus americana) and Mississippi-Sandhill cranes (Grus canadensis pulla).

OBJECTIVE: To assess intraocular pressure (IOP) development in cranes and determine the impact of age, weight, species, head position, and sex. ANIMALS STUDIED: Whooping cranes (WC) (Grus americana), and Mississippi-sandhill cranes (MSC) (Grus canadensis pulla). PROCEDURES: Chicks were manually restrained on days 1-3, 7, 21, 35, 60, 75, and 120 for routine examinations. IOP was opportunistically measured utilizing the Tonovet Plus® in D setting with the head above the heart (AH) and below the heart (BH). Values were also obtained longitudinally in adults (>120 days old) upon presentation in 1 year. RESULTS: Intraocular pressure was highly correlated with age and weight in chicks. For every kilogram gained, IOP increased 2.46 ± 0.08 mmHg in WC and 2.66 ± 0.11 mmHg in MSC. Once hatched, IOP increased 1.13 ± 0.04 mmHg in WC and 0.87 ± 0.04 mmHg in MSC every 10 days. IOP was similar to adults at 120 days of age. In adult WC, mean IOP AH was 24.0 ± 0.4 mmHg, and BH was 27.9 ± 0.4 mmHg, there was a significant difference regarding head positioning and sex, females (25.3 ± 0.4 mm Hg) had lower IOP than males (26.5 ± 0.4 mmHg). In adult MSC, mean IOP AH was 20.7 ± 0.4 mmHg, and BH was 24.6 ± 0.4 mmHg. The difference between head positioning was significant. CONCLUSIONS: This study documents the correlation between IOP and weight or age during early development in cranes, as well as the importance of head positioning.

AIR SAC TREMATODES (CYCLOCOELIDAE STOSSICH, 1902) INFECTING BIRDS IN ZOOLOGICAL INSTITUTIONS IN THE UNITED STATES.

Air sac trematodes (Digenea: Cyclocoelidae) were detected in 23 avian species from eight aviaries in the United States. Most of the infected host species were passeriform birds, but a few species in other orders also were infected. Four species of adult flukes were encountered: Circumvitellatrema momota, Morishitium sp., Psophiatrema greineri, and Szidatitrema yamagutii. Findings from retrospective review of medical records, necropsy records, and author observations are presented. Potential terrestrial snail intermediate hosts were collected from three indoor aviaries. A high prevalence (47%) of larval trematode infections was demonstrated in one species of nonnative snail (Prosopeas achatinacea); one larva was isolated and matched to the adult species (C. momota) from birds using PCR. Problems with introducing potentially infected wild-caught birds into aviaries, and exchanging captive individuals between aviaries where they potentially may carry infections, are discussed.

A Facility-Wide Plan to Increase Access to Medication for Opioid Use Disorder in Primary Care and General Mental Health Settings.

BACKGROUND: The opioid epidemic in the United States has generated a pressing need to enhance access to medications for opioid use disorder (MOUD). This program description illustrates a quality-improvement effort to extend MOUD to primary care and general mental health clinics within the US Department of Veterans Affairs (VA) Connecticut Healthcare system (VACHS), and to examine barriers and facilitators to implementation of MOUD in target clinics. OBSERVATIONS: As part of the national VA Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative to improve MOUD access, a VACHS team identified and resolved barriers to MOUD in target clinics. Key interventions were to obtain leadership support, increase waivered prescribers, and develop processes and tools to enhance prescribing. New initiatives included quarterly educational sessions, templated progress notes, and instant messaging for addiction specialist electronic consultations. MOUD receipt and prescriber characteristics were evaluated before and 1 year after implementation. There was a 4% increase in eligible patients receiving MOUD, from 552 (44%) to 582 (48%) (P = .04). The number of waivered prescribers increased from 67 to 131, and the number of buprenorphine prescribers increased from 35 to 52 over a 6-month span, and the percentage of health care practitioners capable of prescribing within the electronic health record increased from 75% to 89% (P = .01). CONCLUSIONS: An interdisciplinary team approach to identifying and overcoming barriers to MOUD target clinics expands access. Key interventions include interdisciplinary leadership engagement, proactive education and incentivization of target prescribers, removal of procedural barriers, and development of tools to facilitate and support prescribing. These concrete interventions can help inform other institutions interested in expanding MOUD access.

Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force.

During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.

RéSUMé: Pendant la pandémie mondiale du coronavirus (COVID-19), des stratégies urgentes pour réduire les pénuries sont nécessaires. L'évaluation de la faisabilité, de l'aspect pratique et du mérite des stratégies de préservation des médicaments et des alternatives thérapeutiques nécessite une approche collaborative au niveau provincial. Le Groupe de travail ontarien sur les médicaments à l'USI pendant la COVID-19 a reçu comme mandat d'élaborer des recommandations proposant des stratégies de préservation des médicaments et des alternatives thérapeutiques pour les médicaments essentiels utilisés dans les unités de soins intensifs courant un risque de pénurie pendant la pandémie de COVID-19. Des recommandations ont été rapidement élaborées en utilisant une méthode Delphi modifiée, puis évaluées selon leur facilité de mise en œuvre, leur faisabilité et les données probantes les préconisant. Cet article décrit les recommandations quant aux stratégies de préservation des médicaments et aux alternatives thérapeutiques aux médicaments possiblement à risque de pénurie fréquemment utilisés pour les soins des patients en état critique. Les recommandations sont identifiées comme 'à privilégier' ou 'secondaires' si moins souhaitables. Bien que la pandémie de la COVID-19 ait été l'impulsion incitant la création de ce document, ces recommandations devraient également être applicables pour réduire les pénuries de médicaments en contexte normal. Les stratégies provinciales proposées pour la préservation des médicaments et les alternatives thérapeutiques pourraient ne pas être adaptées pour toutes les institutions. La mise en œuvre locale nécessitera la consultation des utilisateurs et des administrateurs hospitaliers. Il faudrait tenir compte des pénuries de matériel concurrentes et des ressources disponibles lors de l'évaluation de la faisabilité de chaque stratégie.

Impact of a Layered Learning Practice Model on Delivery of Clinical Pharmacy Key Performance Indicators under a Tertiary Care Centre Oncology Service.

BACKGROUND: The layered learning practice model (LLPM), within which a pharmacist supervises both a pharmacy resident and a student, mitigates the growing demand for clinical rotations that has accompanied national expansion of Doctor of Pharmacy programs. A Canadian collaborative of hospital pharmacists established consensus on 8 clinical pharmacy key performance indicators (cpKPIs), activities associated with improved patient outcomes. Increased implementation of the LLPM alongside cpKPI measurement offers opportunities to compare the LLPM with standard practice in terms of pharmaceutical care delivery. OBJECTIVE: To quantify clinical productivity, as measured by proportions of eligible patients receiving cpKPIs and absolute numbers of completed cpKPIs, across scenarios involving pharmacists working with and without pharmacy learners. METHODS: In this retrospective observational study, pharmacy students, pharmacy residents, and pharmacists recorded completion of 7 cpKPIs for oncology inpatients over a total of 6 months in 2017 and 2018. Clinical productivity was described across the following 3 scenarios: presence of one or more pharmacists with one resident and one or more students (P-R-S); presence of one or more pharmacists with one or more students (P-S); and presence of one or more pharmacists only (P; standard practice). RESULTS: During the study, there were 685 recorded admissions to the inpatient oncology service. Generally, the proportions of patients who received cpKPIs were similar for scenarios with and without pharmacy learners present. Standardized to 20 pharmacist workdays, the total number of cpKPIs 1, 2, 3, 5, 6, and 7 (255 with P-R-S scenario, 281 with P-S scenario, and 258 with P scenario) and the total number of drug therapy problems resolved (i.e., cpKPI 3; 153 with P-R-S scenario, 180 with P-S scenario, and 149 with P scenario) were similar across the scenarios. Scenario P had fewer admitted patients per pharmacist workday (3.2) than scenarios P-S and P-R-S (3.4 and 3.7, respectively), which may have contributed to a trend toward greater proportions of patients receiving cpKPIs under scenario P. CONCLUSIONS: Compared with standard practice, integration of pharmacy learners within an oncology unit did not appear to impair clinical productivity, as demonstrated by the comparable proportions of patients receiving cpKPIs and the total number of completed cpKPIs.

CONTEXTE: Le modèle de pratique avec apprentissage à plusieurs niveaux (traduction libre de : Layered Learning Practice Model, [LLPM]), où un pharmacien supervise un résident et un étudiant en pharmacie, permet de réduire la demande croissante de stages cliniques qui a suivi le développement national des programmes de doctorat en pharmacie. Un regroupement canadien composé de pharmaciens d'hôpitaux a établi un consensus sur huit indicateurs clés de rendement relatifs à la pharmacie clinique (ICRpc), activités associées à l'amélioration des résultats thérapeutiques. L'accélération de la mise en oeuvre du LLPM, parallèlement à l'évaluation des ICRpc, offre des occasions de comparer le LLPM aux pratiques courantes en ce qui a trait à la prestation de soins pharmaceutiques. OBJECTIF: Quantifier la productivité clinique, en fonction des proportions de patients admissibles, profitant des ICRpc et des nombres absolus d'ICRpc évalués, dans des scénarios où les pharmaciens travaillent ou non avec des étudiants ou des résidents. MÉTHODES: Dans la présente étude d'observation rétrospective, des étudiants et des résidents en pharmacie ainsi que des pharmaciens ont enregistré l'évaluation complète de sept ICRpc pour des patients hospitalisés en oncologie sur une durée totale de six mois en 2017 et 2018. La productivité clinique a été décrite à l'intérieur des trois scénarios suivants : participation d'au moins un pharmacien accompagné d'au moins un résident et un étudiant (P-R-É); participation d'au moins un pharmacien accompagné d'au moins un étudiant (P-É); et participation d'au moins un pharmacien, sans étudiant ou résident (P : pratique courante). RÉSULTATS: Au cours de l'étude, on a enregistré 685 admissions au service d'hospitalisation en oncologie. Généralement, les proportions de patients profitant des ICRpc étaient semblables dans les trois scénarios. Basé sur une unité de mesure de 20 jours de travail de pharmacien, le nombre total d'ICRpc 1, 2, 3, 5, 6 et 7 (255 pour le scénario P-R-É, 281 pour le scénario P-É et 258 pour le scénario P) et le nombre total de problèmes pharmacothérapeutiques réglés (c'est-à-dire ICRpc 3; 153 pour le scénario P-R-É, 180 pour le scénario P-É et 149 pour le scénario P) étaient semblables dans les différents scénarios. Le scénario P présentait moins de patients admis par jours de travail de pharmacien (3,2) que les scénarios P-É et P-R-É (respectivement 3,4 et 3,7), ce qui peut avoir contribué à créer une tendance montrant une plus grande proportion de patients profitant des ICRpc dans le scénario P. CONCLUSIONS: Comparée à la pratique courante, l'intégration d'étudiants ou de résidents en pharmacie dans un service d'oncologie ne semblait pas réduire la productivité clinique, comme l'illustrent les proportions comparables de patients profitant d'ICRpc et le nombre total d'ICRpc évalués.

Effects of galantamine on smoking behavior and cognitive performance in treatment-seeking smokers prior to a quit attempt.

OBJECTIVE: Drugs that enhance cholinergic transmission have demonstrated promise treating addictive disorders. Galantamine, an acetylcholinesterase inhibitor, may reduce cigarette smoking in otherwise healthy treatment-seeking smokers. METHODS: The current study is a double-blind, placebo-controlled, study that randomized daily smokers (n = 60) to receive one of two doses of galantamine extended release (8 or 16 mg/day), or a placebo treatment. Participants completed a smoking choice task as well as study measures and cognitive tasks in the laboratory and daily life using ecological momentary assessment. Analysis focused on smoking behavior and satisfaction, cognitive performance, and decision to smoke prior to a quit attempt. RESULTS: Linear mixed models demonstrated that, compared with placebo, both doses of galantamine reduced smoking in a laboratory choice task (p = 0.006) and decreased urine cotinine levels, but not self-reported cigarettes, during the pre-quit period (p = 0.007). Treatment had minimal effect on smoking satisfaction or cognitive performance. CONCLUSIONS: The results suggest that galantamine reduces nicotine intake but it is unlikely that galantamine improves cognitive performance in otherwise healthy, treatment-seeking smokers. Larger randomized clinical trials can determine if galantamine adjunctive to addiction treatment can improve smoking treatment outcomes.

Momentary Associations Between Reported Craving and Valuing Health in Daily Smokers.

INTRODUCTION: Research suggests that a blunted response to nondrug rewards, especially under conditions associated with strong cigarette cravings, is associated with reduced abstinence motivation in daily smokers. One limitation of previous studies is that they have largely focused on monetary rewards as broad representative of nondrug rewards. It remains unclear whether craving dampens responses to more abstract nondrug rewards, such as personal values. Personal values often have a positive valence and are frequently assumed to remain stable across time and situations. However, there may be time-varying and contextual influences on smokers' appraisal of values in daily life. Characterizing fluctuations in value importance in relation to relapse precipitants (eg, craving) may inform interventions that leverage personal values as motivation for cessation. METHODS: Daily smokers (n = 18) completed ecological momentary assessment surveys measuring the importance of specific personal values and smoking-related variables during 8 days of monetarily reinforced cigarette abstinence. We hypothesized that value ratings would demonstrate adequate within-person heterogeneity for multilevel modeling and that within-person fluctuations in craving would be negatively related to valuing personal health. RESULTS: All values demonstrated adequate within-person variability for multilevel modeling. Within-person craving was negatively related to health valuation (p = .012) and a cross-level interaction (p > .0001) suggested this effect is stronger for individuals who report greater overall craving. CONCLUSIONS: Greater craving is associated with decreased importance of personal health in the moment, particularly for those with high average levels of craving. Timely interventions that bolster importance of health during moments of elevated craving can potentially improve cessation outcomes. IMPLICATIONS: This study builds on research highlighting the positive influence of personal values in motivating behavior change. Values are an often used, but poorly studied, construct that has considerable utility in smoking cessation. Valuing personal health is frequently reported as a primary motivator for a quit attempt. Inasmuch as personal health is a distal nondrug reward used to motivate smoking abstinence, naturalistic evaluation of health importance, and motivators for continued smoking (ie, craving) could inform the timing and content of smoking treatment. This study is among the first to evaluate momentary assessment of personal values and craving within daily life.

Inhalation of Alcohol Vapor: Measurement and Implications.

Decades of alcohol research have established the health risks and pharmacodynamic profile of oral alcohol consumption. Despite isolated periods of public health concern, comparatively less research has evaluated exposure to alcohol vapor. Inhaled alcohol initially bypasses first-pass metabolism and rapidly reaches the arterial circulation and the brain, suggesting that this route of administration may be associated with pharmacological effects that increase the risk of addiction. However, detailed reviews assessing the possible effects of inhaled alcohol in humans are lacking. A comprehensive, systematic literature review was conducted using Google Scholar and PubMed to examine manuscripts studying exposure to inhaled alcohol and measurement of biomarkers (biochemical or functional) associated with alcohol consumption in human participants. Twenty-one publications reported on alcohol inhalation. Fourteen studies examined inhalation of alcohol vapor associated with occupational exposure (e.g., hand sanitizer) in a variety of settings (e.g., naturalistic, laboratory). Six publications measured inhalation of alcohol in a controlled laboratory chamber, and 1 evaluated direct inhalation of an e-cigarette with ethanol-containing "e-liquid." Some studies have reported that inhalation of alcohol vapor results in measurable biomarkers of acute alcohol exposure, most notably ethyl glucuronide. Despite the lack of significantly elevated blood alcohol concentrations, the behavioral consequences and subjective effects associated with repeated use of devices capable of delivering alcohol vapor are yet to be determined. No studies have focused on vulnerable populations, such as adolescents or individuals with alcohol use disorder, who may be most at risk of problems associated with alcohol inhalation.

Validation of the Critical Care Pain Observation Tool in Critically Ill Patients With Delirium: A Prospective Cohort Study.

OBJECTIVES: The 2013 clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU suggest that pain be routinely assessed using a validated pain assessment tool. Currently available tools have only been evaluated in nondelirious critically ill patients, yet delirium can affect as many as 80% of ICU patients. The validated pain assessment tool adopted by our institution is the Critical Care Pain Observation Tool, and the objective of this study was to investigate the validity of this tool in patients with evidence of delirium. DESIGN: Prospective cohort study. SETTING: Two ICUs within a Canadian tertiary healthcare center. PATIENTS: Forty consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU. MEASUREMENTS AND MAIN RESULTS: Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (including mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points. Discriminant validity was described using paired t tests, whereas internal consistency was described using the Cronbach α statistic. Responsiveness of the Critical Care Pain Observation Tool was measured by effect size, and reliability was described as the agreement between raters. Comparisons between the Critical Care Pain Observation Tool and the subjective assessments and objective measurements were based on positive and negative percent agreement. Critical Care Pain Observation Tool demonstrated excellent discriminant validity as evidenced by a highly statistically and clinically significant change in mean Critical Care Pain Observation Tool scores between baseline and painful procedures (mean difference, 3.13 ± 1.56; p < 0.001; Cohen D, 2.0). Interrater agreement was also excellent (κ > 0.6), and scores between raters were highly correlated (r = 0.957). The Critical Care Pain Observation Tool possessed a high level of internal consistency (overall Cronbach α, 0.778). Percent agreement was found to be greater between the Critical Care Pain Observation Tool and the nurse's subjective opinion of the presence or absence of pain when compared with that between the Critical Care Pain Observation Tool and physiologic variables (80.5% vs 67.5%, respectively). CONCLUSIONS: The Critical Care Pain Observation Tool is a valid pain assessment tool in noncomatose, delirious adult ICU patients who are unable to reliably self-report the presence or absence of pain.

Characterization and Multilineage Differentiation of Domestic and Black-Footed Cat Mesenchymal Stromal/Stem Cells from Abdominal and Subcutaneous Adipose Tissue.

Transplantation of mesenchymal stem cells (MSCs) isolated from bone marrow or adipose tissue is emerging as a promising tool for cell replacement therapy and regenerative medicine in domestic and endangered animal species. Defining the differentiation capability of adipose-derived mesenchymal stromal/stem cells (AMSCs) collected from different depot sites of adipose tissue will be essential for developing strategies for cell replacement therapy. In the present study, we compared the biological characteristics of domestic cat AMSCs isolated from visceral fat of the abdominal cavity (AB) with AMSCs from subcutaneous (SQ) tissue, and the functional capability of domestic and black-footed cat (Felis nigripes) AMSCs to differentiate into other cell types. Our results showed that both domestic and black-footed cat adipose-derived stromal vascular fractions contained AMSCs. Both domestic cat AB- and SQ-AMSCs showed important clonogenic ability and the minimal MSC immunophenotype as defined by the International Society for Cellular Therapy in humans. However, domestic cat AB-AMSCs had higher percentages of cells positive for MSCs-associated cluster of differentiation (CD) markers CD90(+) and CD105(+) (92% and 80%, respectively) than those of SQ-AMSCs (77% and 58%, respectively). Although these results may suggest that AB-AMSCs may be more multipotent than SQ-AMSCs, both types of cells showed similar expression of pluripotent genes Oct-4 and Klf4, except for higher expression of Nanog than in AB-AMSCs, and equivalent in vitro multilineage differentiation. Under appropriate stimuli, the black-footed cat and both domestic cat AB- and SQ-AMSCs differentiated not only toward mesoderm cell lineages but also toward ectoderm cell lineage, such as neuron cell-like cells. Black-footed cat AMSCs had more capability to differentiate toward chondrocytes. These results suggest that the defined AMSC population (regardless of site of collection) could potentially be employed as a therapeutic agent for both domestic and endangered diseased or injured felids.

Cloacolithiasis and intestinal lymphosarcoma in an African black-footed penguin (Spheniscus demersus).

A 13-yr-old male African black-footed penguin (Spheniscus demersus) presented thrice over 7 mo with gastrointestinal obstruction secondary to cloacolithiasis. Clinical signs consistently resolved with cloacolith removal and supportive care. However, 10 mo after initial presentation, it presented with similar signs, plus significant weight loss. No cloacolith was found, and it subsequently died. Significant gross findings included bilateral cecal masses, colonic perforation, and marked secondary coelomitis, multifocal tan to pale hepatic nodules, and pale kidneys with miliary white foci. Histopathologic diagnoses were intestinal lymphosarcoma with hepatic and renal metastases, secondary intestinal rupture, and subacute severe bacterial coelomitis. To the authors' knowledge, this is the first full report of either cloacolithiasis or lymphosarcoma in a penguin.

Integrating ecological momentary assessment and functional brain imaging methods: new avenues for studying and treating tobacco dependence.

INTRODUCTION: Ecological momentary assessment (EMA) and related methods typically entail repeatedly and intensively sampling behavior as it occurs over time and under naturalistic conditions. Although the methodological features of EMA make it a highly valuable research technique in its own right, EMA can also be a potent counterpart to other approaches. One methodological partnership with substantial yet largely untapped potential for the study of tobacco dependence is the pairing of EMA with functional brain imaging. METHODS: The goal of this review is to outline the promise of this approach, with a focus on the combined use of EMA and functional magnetic resonance imaging (fMRI). Due to the unique and complementary strengths of each method, the merger of EMA and fMRI methods has the potential to advance the understanding of tobacco dependence in ways difficult or impossible to achieve through the use of either method in isolation. RESULTS: In addition to describing a conceptual basis for combining EMA with fMRI, we provide a preliminary empirical illustration of this integrative approach using data from an ongoing study. CONCLUSIONS: EMA and fMRI have independently yielded important findings regarding the nature and treatment of tobacco dependence. The integration of these powerful research methods, however, holds even greater potential for the field of tobacco research. Additionally, recent advances are paving the way for the synergistic use of fMRI and EMA-based methods to develop innovative approaches to tobacco cessation.

Impaired gastrointestinal transit and its associated morbidity in the intensive care unit.

PURPOSE: To determine the proportion of critically ill adults developing impaired gastrointestinal transit (IGT) using a clinically pragmatic definition, its associated morbidity and risk factors. MATERIALS AND METHODS: Critically ill adult patients receiving enteral nutrition for ≥ 72 hours and mechanically ventilated for ≥ 48 hours were prospectively identified. IGT was defined as absence of a bowel movement for ≥ 3 days, treatment for constipation, and one of the following: (1) radiologic confirmed ileus, (2) feed intolerance, (3) abdominal distention, or (4) gastric decompression. RESULTS: One thousand patients were screened, and 248 were included for analysis. Fifty patients (20.1%; 95% confidence interval, 15.1-25.6%) developed IGT persisting for 6.5 ± 2.5 days. Patients with IGT had longer lengths of intensive care unit stay and were less likely to reach nutrition targets compared to patients without IGT or traditional definitions of constipation. Daily opioid use and pharmacological constipation prophylaxis were identified risk factors for IGT. CONCLUSION: Traditional definitions of constipation or ileus in intensive care unit patients are simplistic and lack clinical relevance. Pragmatically defined IGT is a common complication of critical illness and is associated with significant morbidity. Future interventional studies for IGT in critically ill adults should use a more clinically relevant definition and evaluate energy deficits and lengths of stay as clinically relevant outcomes.

The hypnotic zolpidem increases the synchrony of BOLD signal fluctuations in widespread brain networks during a resting paradigm.

Networks of brain regions having synchronized fluctuations of the blood oxygen level-dependent functional magnetic resonance imaging (BOLD fMRI) time-series at rest, or "resting state networks" (RSNs), are emerging as a basis for understanding intrinsic brain activity. RSNs are topographically consistent with activity-related networks subserving sensory, motor, and cognitive processes, and studying their spontaneous fluctuations following acute drug challenge may provide a way to understand better the neuroanatomical substrates of drug action. The present within-subject double-blind study used BOLD fMRI at 3T to investigate the functional networks influenced by the non-benzodiazepine hypnotic zolpidem (Ambien). Zolpidem is a positive modulator of γ-aminobutyric acid(A) (GABA(A)) receptors, and engenders sedative effects that may be explained in part by how it modulates intrinsic brain activity. Healthy participants (n=12) underwent fMRI scanning 45 min after acute oral administration of zolpidem (0, 5, 10, or 20mg), and changes in BOLD signal were measured while participants gazed at a static fixation point (i.e., at rest). Data were analyzed using group independent component analysis (ICA) with dual regression and results indicated that compared to placebo, the highest dose of zolpidem increased functional connectivity within a number of sensory, motor, and limbic networks. These results are consistent with previous studies showing an increase in functional connectivity at rest following administration of the positive GABA(A) receptor modulators midazolam and alcohol, and suggest that investigating how zolpidem modulates intrinsic brain activity may have implications for understanding the etiology of its powerful sedative effects.

Presumed reactive polyarthritis and granulomatous vasculitis in a Mississippi sandhill crane (Grus canadensis pulla).

A 1.5-year-old female Mississippi sandhill crane (Grus canadensis pulla) was presented and managed for a polyarthritis of the intertarsal and tarsophalangeal articulations. Results of aerobic bacterial cultures, Mycoplasma species culture, and polymerase chain reaction testing of articular fluid did not identify any causative organisms. Results of radiographs and cytologic examination of articular fluid were consistent with an inflammatory, nonerosive polyarthritis. The arthritis did not improve with systemic anti-inflammatory and antibiotic treatment and with joint lavage. A large necrotic granulomatous mass was detected on the right shoulder area from which Staphylococcus aureus and Enterococcus species were isolated as opportunistic pathogens. Two days after surgical resection of the mass, the distal polyarthritis resolved. Histopathologic examination of the mass was consistent with granulomatous vasculitis with abscess formation of unknown origin. In this crane, the unresponsiveness to standard therapy, the presence of an infected and inflammatory mass, and the resolution of the polyarthritis after the resection of the mass strongly supported a diagnosis of reactive immune-mediated nonerosive polyarthritis. Analysis of this case suggests that immune-mediated idiopathic arthritis should be a differential diagnosis of distal polyarthritis in cranes and that an inciting source remote from the joints should be investigated in case of lack of response to standard therapy.

Nicotine content and abstinence state have different effects on subjective ratings of positive versus negative reinforcement from smoking.

Despite the well-known adverse health consequences of smoking, approximately 20% of US adults smoke tobacco cigarettes. Much of the research on smoking reinforcement and the maintenance of tobacco smoking behavior has focused on nicotine; however, a number of other non-nicotine factors are likely to influence the reinforcing effects of smoked tobacco. A growing number of studies suggest that non-nicotine factors, through many pairings with nicotine, are partially responsible for the reinforcing effect of smoking. Additionally, both clinical studies and preclinical advances in our understanding of nicotinic receptor regulation suggest that abstinence from smoking may influence smoking reinforcement. These experiments were conducted for 2 reasons: to validate a MRI-compatible cigarette smoking device; and to simultaneously investigate the impact of nicotine, smoking-associated conditioned reinforcers, and smoking abstinence state on subjective ratings of smoking reinforcement. Participants smoked nicotine and placebo cigarettes through an fMRI compatible device in an overnight-abstinent state or in a nonabstinent state, after having smoked a cigarette 25minutes prior. Outcome measures were within-subject changes in physiology and subjective ratings of craving and drug effect during the smoking of nicotine or placebo cigarettes on different days in both abstinence states. Cigarette type (nicotine vs. placebo) had a significant effect on positive subjective ratings of smoking reinforcement ("High", "Like Drug", "Feel Drug"; nicotine>placebo). In contrast, abstinence state was found to have significant effects on both positive and negative ratings of smoking reinforcement ("Crave", "Anxiety", "Irritability"; abstinence>nonabstinence). Interaction effects between abstinence and nicotine provide clues about the importance of neuroadaptive mechanisms operating in dependence, as well as the impact of conditioned reinforcement on subjective ratings of smoking-induced high.

Cardiac glycoside toxicity: more than 200 years and counting.

Digitalis toxicity produces a toxidrome characterized by gastrointestinal, neurologic, electrolyte, and nonspecific cardiac manifestations. Chronic toxicity remains much more difficult to recognize compared with an acute presentation because of the nonspecific manifestations; therefore, serum glycoside levels are essential for diagnosis in this population. The mainstay of management continues to be rapid toxidrome identification followed by digoxin-specific antibody fragment therapy with supportive care. Several controversies still remain, including therapy for patients dependent on hemodialysis, appropriateness of calcium therapy for hyperkalemia, ideal agents for arrhythmia therapy, and the potential utility of plasmapheresis for removal of bound digoxin-antibody fragment complexes.

Effects of transcutaneous electric acupoint stimulation on drug use and responses to cue-induced craving: a pilot study.

BACKGROUND: Transcutaneous electric acupoint stimulation (TEAS) avoids the use of needles, and instead delivers a mild electric current at traditional acupoints. This technique has been used for treating heroin addiction, but has not been systematically tested for other drugs of abuse. This study aims to investigate the effects of TEAS on drug addiction. METHODS: Volunteers who were either cocaine-dependent (n = 9) or cannabis-dependent (n = 11) but were not seeking treatment for their dependence participated in a within-subject, single-blind study. Treatment consisted of twice daily 30-minute sessions of TEAS or sham stimulation for 3.5 days. The active TEAS levels were individually adjusted to produce a distinct twitching response in the fingers, while the sham stimulation involved 2 minutes of stimulation at threshold levels followed by 28 minutes of stimulation below the detection levels. The participants recorded their drug use and drug cravings daily. At 1 hour after the last morning session of TEAS or sham stimulation, a cue-induced craving EEG evaluation was conducted. Event-related P300 potentials (ERPs) were recorded, sorted, and analyzed for specific image types (neutral objects, non-drug-related arousing images, or drug-related images). RESULTS: TEAS treatment did not significantly reduce the drug use or drug cravings, or significantly alter the ERP peak voltage or latency to peak response. However, the TEAS treatment did significantly modulate several self-reported measures of mood and anxiety. CONCLUSION: The results of this pilot study with a limited sample size suggest that the acupoint stimulation techniques and protocol used in this trial alone do not significantly reduce cravings for or use of cocaine or cannabis. The findings that TEAS modulates mood and anxiety suggest that TEAS could be used as an adjunct in a multimodal therapy program to treat cocaine and cannabis dependence if confirmed in a full randomized controlled clinical trial.

Ventricular diverticula formation in captive parakeet auklets (Aethia psittacula) secondary to foreign body ingestion.

A captive parakeet auklet at the North Carolina Zoo evaluated for weight loss, lethargy, and dyspnea had radiographic evidence of a distended, stone-filled ventriculus (bird 1). Multiple stones (n = 76) were removed surgically, but the bird died and a large ventricular diverticulum was diagnosed at necropsy. This bird and seven other parakeet auklets had been transferred 3 yr earlier from a zoo in Ohio. Radiographic investigation revealed that 6 of 7 Ohio birds had stones in their ventriculus (n= 2-26), but only 1 of 7 radiographed North Carolina Zoo auklets had one small stone. Further diagnostic imaging (survey and contrast radiographs, fluoroscopy, CT scans [n = 2]) of six Ohio and two North Carolina birds was conducted to determine if other birds had ventricular abnormalities (birds 2-9). No ventricular diverticula were diagnosed using imaging techniques, although two Ohio birds (birds 6 and 7) required surgical intervention to remove 12-26 stones. A small ventricular diverticulum was identified in bird 6 during surgery. That bird died of unrelated causes 11 mo after surgery, but bird 7 remains clinically normal more than 4 yr later, along with four other auklets with stones (n = 2-15; birds 2-5). It is possible that without surgical intervention, these birds may develop ventricular disease, presumably due to chronic mechanical trauma to the thin-walled ventriculus. It was hypothesized that the Ohio birds ingested stones in their previous exhibit, with a loose stone substrate, and retained them for at least 3 yr. Possible causes for stone ingestion include trituration (for grinding, mixing coarse ingesta), gastric parasite reduction, hunger suppression, accidental ingestion while feeding, or behavioral causes, but the underlying cause in these birds was not determined. Based on these results, parakeet auklets and other alcids should not be housed, or at least fed, on a loose stone substrate.