Contemporary Management and Prevention of Vaso-Occlusive Crises (VOCs) in Adults With Sickle Cell Disease.

Sickle cell disease (SCD) is a hematological disorder that primarily affects individuals of African descent from sub-Saharan Africa and along the mediterranean. The main complications leading to hospitalizations include vaso-occlusive crises (VOCs) and acute chest syndrome (ACS). Therefore, the main objective of this paper was to identify and evaluate evidence-based management and prevention of VOCs in patients with SCD. A literature search of PubMed, Medline Cochrane and Google Scholar database (January 1985 to April 2020) was performed using the following search terms "vaso-occlusive crises", "sickle cell disease", "hydroxyurea", "L-glutamine", "voxelotor", "crizanlizumab", "treatment" and "prevention" as well as a combination of these terms. All English-language interventional studies assessing the efficacy and safety of VOC outcomes were evaluated. Literature was excluded if published in a language other than English or if it was a review article. A total of 69 articles were identified and there were 7 articles that met the search criteria. Majority of the studies focused on mean and median annual rates of VOCs as primary outcomes while median time to first sickle cell crises, median rates of hospitalizations etc were evaluated as secondary outcomes. After reviewing the literature, many patients with VOCs will still benefit from hydroxyurea therapy since long term efficacy data and cost is still a concern for the newer agents including L-glutamine, voxelotor and crizanlizumab. Other factors such as cost or compliance may also be taken into consideration when making recommendations for therapy.

Spatial distribution of emotional attentional blink under top-down attentional control.

Emotion-induced blindness (EIB) refers to the impaired perception of a neutral target that follows an emotional distractor within the time gap of 100-500 ms. Recent studies on EIB show that EIB is spatially localized. Blink occurs when both target and emotional distractor appear in the same stream but not the opposite. However, the influence of top-down attentional control over the dual-stream EIB remains poorly understood. Examining the role of top-down control in EIB will help understand the impact of attentional control over the spatial distribution of EIB and in understanding the Attentional Blink (AB) and EIB distinction. Hence, in the present study, we used dual-stream and manipulated the attentional control by changing the relevance of the emotional image and asking participants to report both emotional and neutral targets. Our results show a similar level of blink irrespective of the spatial location of the emotional T1, suggesting the role of attentional control on the spatial distribution of EIB and in the AB-EIB distinction. Results have implications for the theoretical understanding of EIB.

Rates of Opioid Misuse Amongst Patients Receiving Pain Management for Sickle Cell Disease in An Urban Setting.

Background and Objective: Sickle Cell Disease (SCD) is known to cause acute severe pain episodes known as vaso-occlusive crisis (VOC) mainly treated with opioid analgesics. Since the opioid epidemic there is an interest in determining the opioid misuse potential in these patients. Therefore, the primary objective of this study is to determine the rates of opioid misuse among patients with SCD by assessing the rate of unexpected drug screening results in a sickle cell disease clinic. Methods: This was a retrospective chart review study conducted at the outpatient sickle cell disease clinic. The primary independent variables were the prescribed opioid medications while the primary dependent variable was the collected opioid metabolite. Descriptive statistics, linear regression and multivariate logistic regression analysis were conducted using SPSS version 24. Results: A total of 100 participants were recruited from July 1, 2018, to June 30, 2020 with 71 included in the analysis. The total mean of morphine milligram equivalents (MME) for all participants was 71.1±104.9 with 71% of participants having a daily calculated MME of <90MME. The odds of misusing an opioid were 6.72 times higher (P<.02) if a participant used marijuana compared to a participant who didn't. In addition, the odds of misusing an opioid were 2.47 times higher (P<.04) if the patient was prescribed an opioid daily dose greater than 90 MME as opposed to a daily dose less than 90 MME. Conclusion: Participants who consumed greater than 90 MME's per day and utilized marijuana were more likely to misuse opioids.

Self-Prioritization Effect in Children and Adults.

Self-related information is processed with priority, an effect known as the self-prioritization effect (SPE). Recent studies on SPE show enhanced cognitive processing of the newly learned self-association compared to non-self (such as mother, friend, and stranger) associations among younger and older adults. However, developmental influences on the magnitude of SPE remain poorly understood. In order to examine the developmental impacts on the SPE, in the present study, we recruited participants ranging from 9-22 years of age and divided them into three age groups: older children (age 9-13), teenagers (age 14-17), and young adult (age 18-22) and compared their performance in the matching judgment task. Our results show more significant bias toward self than mother, friend, or stranger condition in all the three age groups, showing robust SPE in the 9-22-year-old age group. We also observed a more significant bias toward mother-association than friend and stranger-association in all the age groups showing an enhanced bias toward mother. Our study extends the SPE in older children and teenagers and shows that SPE remains robust and stable throughout childhood.

Challenges in Treating Mycobacterium chelonae/abscessus Prosthetic Joint Infection.

Prosthetic joint infections (PJIs) remain a major complication of arthroplasty, most of which are caused by Staphylococcus aureus and gram-negative bacteria. Unfortunately, cultures are false negative in upward of 7 percent of patients with suspected PJIs, and commonly in infections caused by rare rapidly growing mycobacterium (RGM) species. Guidelines recommend 6 months of antimycobacterial therapy for bone diseases caused by RGM, with empiric therapy consists of an oral macrolide (clarithromycin or azithromycin) plus tobramycin and imipenem-cilastatin. Definitive treatment of PJI due to RGM should be guided by antimicrobial susceptibility, however, most microbiology laboratories are unable to differentiate between M. chelonae and M. abscessus. Furthermore, treatment of M. chelonae PJI is challenging due to multidrug resistance and the dearth of oral antibiotics for therapy. This case report investigates a patient with PJI caused by M. chelonae and M. abscessus. The initial treatment with imipenem-cilastatin was complicated by drug induced seizures, further limiting therapy options.

Effects of Pharmacist-Conducted Medication Reconciliation at Discharge on 30-Day Readmission Rates of Patients With Chronic Obstructive Pulmonary Disease.

PURPOSE: To analyze effect of pharmacist-conducted medication reconciliation on 30-day readmission rates in chronic obstructive pulmonary disease (COPD) and identify common medication errors among patient with readmissions. METHODS: Pharmacists were educated on discharge medication reconciliation for patients with COPD. A retrospective chart review was conducted on patients who underwent pharmacist-conducted discharge medication reconciliation to determine 30-day readmissions. Medication errors analyzed included medication omissions and dose or frequency errors. Previously collected internal research without pharmacist-conducted medication reconciliation served as the control. RESULTS: There were 65 patients in the control group and 50 in the intervention group. About 25% of patients in the control group and 26% of patients in the intervention group had any cause readmissions within 30 days of discharge (P = .87). Both the control and the intervention group had similar COPD-related readmissions of 12.3% and 12.6%, respectively. Medication dose or frequency errors consisted of 68.9% and 46.7% of total errors in the control and the intervention groups, respectively. Long-acting muscarinic antagonist (LAMA) or long-acting beta 2-agonist (LABA) were the most common drug classes to be incorrectly dosed or omitted at discharge. In the intervention group, 30 errors were identified. Due to inability to coordinate discharges, pharmacists intervened on 13 errors, 7 of which were accepted by the prescriber. CONCLUSION: Pharmacist-conducted medication reconciliation at discharge did not affect 30-day readmission rates of patients with COPD. Confounding factors included a small sample size, passive pharmacist education, and discharge issues. The most common medication errors at discharge were dosing or frequency errors of LABAs or LAMAs.

Andexanet alfa for reversal of factor Xa inhibitor-associated anticoagulation.

BACKGROUND: Review of clinical data on andexanet alfa for the reversal of factor Xa (FXa) inhibitor associated anticoagulation. DATA SOURCES: In the present review, we identified articles via PubMed using the combined keywords andexanet alfa, apixaban, enoxaparin, edoxaban, and rivaroxaban. Additional online searches via PubMed, Google Scholar, and Lexicomp were conducted for both prescribing and cost information. Portola Pharmaceuticals was contacted for information used for United States Food and Drug Administration approval of andexanet alfa. STUDY SELECTION AND DATA EXTRACTION: English-language clinical trials and reviews published between January 2008 and April 2019 were included for review. Bibliographies of selected articles were reviewed manually for relevant publications, focusing on reversal strategies for apixaban, enoxaparin, edoxaban, or rivaroxaban associated anticoagulation using andexanet alfa. Review articles were excluded. DATA SYNTHESIS: The safety and tolerability of andexanet alfa were evaluated in one phase I, two phase II, and one phase III clinical trials. The use of andexanet alfa for reversing FXa inhibitor-associated anticoagulation were evaluated in the phase III ANNEXA-4 study. CONCLUSIONS: Studies evaluating laboratory parameters for coagulation show that andexanet alfa rapidly neutralizes the anticoagulant effects of apixaban, enoxaparin, edoxaban, and rivaroxaban. Clinical studies show that andexanet alfa improves markers related to coagulation, and reverses major bleeding in healthy volunteers and patients with life-threatening bleeding. Interruption of anticoagulation may result in thromboembolic and ischemic events. The use of andexanet alfa requires close monitoring for signs and symptoms of thromboembolic events, ischemic events, and cardiac arrest. Furthermore, anticoagulation should be resumed following the administration of andexanet alfa as soon as medically appropriate.

Chronic Lymphocytic Leukemia Presenting as a Subcortical Watershed Infarct.

Internal watershed infarcts (WI) involve white matter between deep and superficial arterial systems of middle cerebral artery. These infarcts are considered to be either from low blood flow or microembolism. Anemia is an extremely rare cause of watershed infarcts. Very few cases of hemolytic anemia causing watershed cerebral infarcts have been reported. Chronic lymphocytic leukemia (CLL) is frequently complicated with secondary autoimmune cytopenia such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and pure red cell aplasia. AIHA is present in about 7-10% of patients with CLL. AIHA from CLL presenting as WI is an extremely rare phenomenon with no previously published case reports to the best of our knowledge.

Emotion Induced Blindness Is More Sensitive to Changes in Arousal As Compared to Valence of the Emotional Distractor.

Emotion Induced Blindness (EIB) refers to the impairment in the identification of a neutral target image that follows a threatening or fearful distractor image. It has been suggested that valence plays a significant role in driving the perceptual impairment in EIB. Recent findings from the literature suggest that arousal has a very important role in biasing early cognitive functions. Hence, in the present study, we systematically investigate the role of valence (Experiment 1) and arousal (Experiment 2) in determining the impairment in EIB. The results suggest that when valence is controlled for, the stimuli with higher arousal level lead to greater impairment in target detection. Moreover, under high arousal condition, both positive and negative stimuli lead to significantly greater impairment in target detection. Present study suggests that impairment in EIB is sensitive to the arousal component of the emotional image as compared to valence. The arousal biased competition account that explains the effect of arousal on cognitive processing can sufficiently explains the current results.