Special Issue: Emergency Medicine: Clinical Advances and Challenges in Diagnosis and Treatment.

The development of Emergency Medicine brings various challenges [...].

Bio-optical trends of waters around Valdés Biosphere Reserve: An assessment of the temporal variability based on 20 years of ocean color satellite data.

Satellite Image Time Series are becoming increasingly available and will continue to do so in the coming years thanks to the launch of space missions which aim to provide a high spatial resolution coverage of the Earth every few days. Bio-optical characteristics and their variation over time have been poorly studied in the Patagonian shelf. In this paper, we present the trends of time series analysis from satellite images that allows us to interpret the variations of bio-optical properties throughout time and their implications for planktonic organisms. The annual and seasonal trends of six variables were analyzed for two different gulfs, Nuevo and San José, in northern Patagonia from January 2003-December 2021. We present the dynamic temporal changes of chlorophyll a (Chla-sat), phytoplankton absorption (Ab_phy), detritus absorption as well as environmental features changes for the sea surface temperature (SST), depth of the euphotic zone (Z_eu) and photosynthetically active radiation (PAR). We found positive trends for SST, Ab_phy at 443 nm and PAR, but negative for Z_eu in Nuevo and San José gulfs. The positive trendlines for SST and negative for Z_eu suggest less availability of nutrients and light. These trends could change the bloom phenology and modify the phytoplankton community structure with implications for the entire food web and the ecosystem services in the VBR.

Predicting drug-drug and drug-gene interactions in a community pharmacy population.

OBJECTIVES: Drug-drug interactions (DDIs) are among the most common causes of adverse drug reactions and are further complicated by genetic variants of drug-metabolizing enzymes. The aim of this study is to quantify and describe potential DDIs, drug-gene interactions (DGIs), and drug-drug-gene interactions (DDGIs) in a community-based population. STUDY DESIGN: This was an analysis of deidentified retail pharmacy prescription data for 4761 individuals. METHODS: Data were first assessed for DDIs, and individuals were stratified to a risk category using the logic of a commercially available digital DDGI tool. To calculate the frequency of potential DGIs and DDGIs, genotypes were imputed and randomly allocated to the cohort 100 times via Monte Carlo simulation according to each variant's frequency in the general population. RESULTS: The probability of a DDI of any impact was 26.0% and increased to 49.6% (95% CI, 48.4%-50.7%) when drug-metabolizing phenotypes were ascribed according to the distribution of variants of 11 genes as found in a Caucasian population. There was a 7.8% probability of major DDIs, which increased to a 10.1% (95% CI, 9.5%-10.8%) probability with the addition of genetic contributions. The probability of DDGIs of any impact was correlated with the number of medications. Antidepressants, antiemetics, blood products and modifiers, analgesics, and antipsychotics had the highest probability of DDGIs. CONCLUSIONS: The probability of drug interaction risk increased when phenotypes associated with genetic polymorphisms were attributed to the population. These data suggest that pharmacogenomic assessment may be useful in predicting drug interactions and severity when evaluating patient medication profiles.

Phytoplankton dynamics based on satellite inherent optical properties and oceanographic conditions in a patagonian gulf frontal system in relation to the adjacent continental shelf waters.

The dynamics of phytoplankton across a seasonal frontal system formed in San José Gulf (SJG, Patagonia Argentina) and in neighbouring shelf waters was assessed based on bio-optical satellite data (2003-2018) and spring and summer in situ samplings. Bio-optical properties of the water masses on the eastern (ED) and western (WD) domains of the seasonal frontal system of SJG showed clear differences: the year-round-vertically-mixed waters from the WD, strongly connected with the adjacent shelf waters, evidenced a brief and strong single phytoplankton bloom, while those from the ED, showing lower exchange with shelf waters and a strong vertical stratification during the warm season, displayed an earlier and long-lasting spring phytoplankton bloom, followed by a late-summer and autumn bloom, both associated with the development and erosion of the seasonal thermocline. Waters from the entire system are optically influenced by the absorption of coloured dissolved organic matter and detritus (cdom + detritus), suggesting a strong sediment load contribution from the continent and the seabed. To remark, a strong correlation between satellite chlorophyll-a (Chla-sat) and absorption by phytoplankton (aphy443) in the outer shelf waters differs from the weak correlation of those variables in the gulf's water masses, whose optical parameters are more complex. In situ Chla records may indicate wind-driven upwelling and downwelling areas in the northern and southern coasts of the ED. Dissolved nitrogen was identified as the limiting macronutrient for phytoplankton growth in the ED during summer. This work contributes relevant ecological information that may support management actions on the SJG shellfish artisanal fishery.

Accuracy of a single-lead mobile smartphone electrocardiogram for QT interval measurement in patients undergoing maintenance methadone therapy.

STUDY OBJECTIVE: Methadone is associated with QT interval prolongation and torsades de pointes. Expert panel recommendations advocate a pre-methadone electrocardiogram (ECG) and another ECG at 30 days of therapy in patients with risk factors. Some guidelines recommend a pre-methadone ECG and routine ECG monitoring in all methadone patients, but this is controversial due to the resources required. Availability of a convenient, less resource-intensive method of ECG monitoring for patients taking methadone is desirable. The objective of this study was to assess the accuracy of a handheld smartphone ECG (iECG) for QT measurement in patients on maintenance methadone therapy in an urban opioid treatment program. DESIGN: Prospective study. SETTING: Urban opioid treatment program. PATIENTS: n = 115 patients in normal sinus rhythm who were on steady-state maintenance methadone therapy INTERVENTION: Patients (n = 115) underwent a simultaneous 12-lead ECG and a single-lead iECG. MEASUREMENTS AND MAIN RESULTS: The first three QT and RR intervals from lead II of the 12-lead ECG and simulated lead I from the iECG were compared using the Bland-Altman analysis of measurement agreement. Mean [± standard deviation) age was 34 ± 11 years; 71% were female, 75% were white. Compared to the 12-lead ECG, the iECG was associated with a QTc bias of - 0.14 ms (SD = 12 ms, 95% CI = -2.4 to 2.1 ms). The absolute mean difference in QTc between the two methods was 9.5 ± 7.1 ms. For identification of patients with methadone-associated QTc prolongation, the iECG performed moderately well [c-statistic 0.97 (95% CI 0.91-0.99); sensitivity and specificity 75% (95% CI 43-95%) and 99% (95% CI 94-99%), respectively]. The positive and negative likelihood ratios of the iECG for identifying patients with methadone-associated QTc prolongation were 77.25 (95% CI 10.69 to 558.18) and 0.25 (95% CI 0.09 to 0.67), respectively, while the positive and negative predictive values were 90% (95% CI 56-99%) and 97% (95% CI 92-99%), respectively. The accuracy of the iECG for identifying patients with QTc prolongation was 97% (95% CI 91-99%). CONCLUSION: A handheld smartphone ECG is accurate for QT interval measurement in patients taking maintenance methadone therapy, and its performance is moderately good for identifying patients with methadone-associated QTc prolongation.

Methadone-associated QT interval prolongation in patients undergoing maintenance therapy in an urban opioid treatment program.

STUDY OBJECTIVE: Methadone is associated with QT interval prolongation and torsades de pointes. The objective of this study was to (a) determine the incidence of QT interval prolongation among patients on maintenance methadone therapy in an urban opioid treatment program (OTP), (b) compare characteristics of patients who developed methadone-associated QT prolongation with those who did not develop QT prolongation, and (c) investigate the relationship between QT interval prolongation and stereospecific serum methadone and metabolite [2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP)] concentrations. DESIGN: Prospective study. SETTING: Urban opioid treatment program (OTP). PATIENTS: n = 93 patients on maintenance methadone therapy in an urban OTP. INTERVENTION: Patients underwent a 12-lead electrocardiogram (ECG) prior to initiating methadone and again during steady-state maintenance methadone therapy. In a subset (n = 43), blood was obtained to determine serum (S)- and (R)-methadone and (S)- and (R)-EDDP concentrations, which were compared in patients who developed Bazett's-corrected QT (QTc) prolongation [≥470 ms (men) or ≥480 ms (women) and/or ≥60 ms lengthening from pretreatment value] with those who did not have QTc prolongation. MEASUREMENTS AND MAIN RESULTS: Mean [± standard deviation (SD)] age was 36 ± 12 years; 73% were female, and 74% were white. QTc prolongation occurred in 14 (15.1%) patients. Patients who developed QTc prolongation were older (41 ± 13 vs. 35 ± 9 years, p = 0.03) and had a longer pre-methadone QTc compared with those who did not have QTc prolongation (429 ± 11 vs. 420 ± 20 ms, respectively, p = 0.02). Serum (S)-methadone concentrations were higher in patients with QTc prolongation compared to patients without prolongation (199 ± 81 vs. 128 ± 68 ng/ml, respectively, p = 0.01), whereas the difference in serum (R)-methadone concentrations between the groups did not reach significance (189 ± 68 vs. 125 ± 60 ng/ml, respectively, p = 0.08). Serum (R)-methadone concentrations correlated with QTc intervals [R2  = 0.15 (95% confidence interval (CI) 0.11-0.62, p = 0.0009)]. The correlation between serum (S)-methadone concentrations and QTc did not reach significance [R2  = 0.08 (95% CI -0.01 to 0.54, p = 0.06)]. Serum (S)-and (R)-EDDP concentrations were not significantly different between the groups and did not significantly correlate with QTc intervals. CONCLUSIONS: Approximately 15% of patients taking maintenance methadone therapy developed QT interval prolongation. Both serum (S)- and (R)-methadone concentrations, but not (S)- or (R)-EDDP, contribute to methadone-associated QT prolongation.

Spring and summer ichthyoplankton assemblages in a temperate Patagonian gulf: an overview of temporal and spatial patterns on their structure.

Knowing about the spatio-temporal patterns in the structure of ichthyoplankton assemblages allows inferring about the spawning behaviour of adult fishes, understanding the recruitment dynamics, and predicting the potential effects of mid- and long-term changes. Here, we studied the ichthyoplankton assemblages from the San José Gulf (Northern Patagonia, Argentina) and investigated their changes in space and time. To do that, we took monthly samples during two consecutive years, in spring and summer. A total of 2088 larvae were caught; they comprised 36 taxa, from which 14 were identified to species, two to genus, one to family and one to order. There were large differences in the structure of the assemblages between years, coincidently with marked changes in the surface water temperature. The structure of the ichthyoplankton assemblages also showed significant differences between the spring and summer: Helcogrammoides cunninghami, Dules auriga and larvae belonging to the family Engraulidae contributed most to these differences. The species diversity was higher in the colder year than in the warmer one. We discuss the potential role of environmental and oceanographic features on the interannual variability in the early stages of coastal fishes within a small gulf.

Metabolic monitoring of second-generation antipsychotics: Evaluation of a pharmacist- and nurse-driven protocol.

OBJECTIVE: Second-generation antipsychotic therapy can lead to metabolic abnormalities, increasing the risk of cardiovascular disease and death in patients with serious mental illness. However, the literature suggests there is a lack of appropriate monitoring in individuals receiving these therapies. This study aims to evaluate whether the implementation of a pharmacist- and nurse-driven metabolic monitoring protocol will increase monitoring in patients prescribed second-generation antipsychotic therapy in an outpatient community mental health clinic. METHODS: A retrospective review of adult outpatients in a community mental health clinic who were prescribed second-generation antipsychotics was conducted from October 1, 2017, to March 31, 2019. Pre- and postprotocol implementation groups were compared to assess the impact of the protocol on the primary outcome of appropriateness in monitoring for metabolic parameters. RESULTS: A total of 160 patients who met the inclusion criteria were randomly selected and reviewed, allowing for 80 individuals in each group. Improvement in the appropriateness of monitoring was found for 4 of 5 metabolic parameters after protocol implementation, including blood pressure (17.5% to 43.8%, P < 0.001), weight (17.5% to 43.8%, P < 0.001), hemoglobin A1C (27.5% to 42.5%, P = 0.044), and lipid levels (17.5% to 31.3%, P = 0.04). Primary care physicians ordered most of the laboratory values (44.5% to 46.2%); however, pharmacists and nurses ordered 7% of laboratory tests after the protocol implementation. CONCLUSION: Despite the knowledge that second-generation antipsychotic therapies commonly lead to metabolic syndrome and therefore increased cardiovascular disease risk, monitoring for metabolic effects remains poor, and there is a lack in diversity of strategies to improve this monitoring. Although further research on the effectiveness of a pharmacist- and nurse-driven metabolic monitoring protocol in this setting is warranted, this protocol serves as an example of a novel strategy with the potential to improve metabolic monitoring of second-generation antipsychotic therapy.

The evolving role of the pharmacist for individuals with serious mental illness.

Adults with serious mental illness such as schizophrenia, bipolar disorder, or severe depression encounter many barriers in receiving appropriate health care services and are at a markedly increased risk of premature mortality. A range of clinical pharmacist roles in community mental health may help offset the increasing issues related to access to care and contribute to recovery-oriented systems of care for individuals with serious mental illness. In this commentary, we offer a description of one such model operationalized within a large community mental health center. Clinical pharmacists provide substantial contributions toward optimizing care for individuals with serious mental illness through medication therapy management, cardiovascular risk reduction, and various other interventions to help positively impact the health disparity these individuals face.

At-a-glance - The Child Maltreatment Surveillance Indicator Framework. / Aperçu - Cadre des indicateurs de surveillance de la maltraitance envers les enfants.

The federal health portfolio has conducted surveillance on child maltreatment as a public health issue since the 1990s. The Public Health Agency of Canada (PHAC) is now releasing the Child Maltreatment Indicator Framework, to take its place alongside other PHAC frameworks, such as the Suicide Surveillance Indicator Framework. Based on a scoping review of existing reviews and meta-analyses, this Framework, along with the online interactive data tool, presents child maltreatment outcome indicators and risk and protective factors at the individual, family, community and societal levels, disaggregated by sex, age and other sociodemographic variables. This Framework will function as a valuable resource pertaining to an issue that affects at least one in three Canadian adults.

The Child Maltreatment Surveillance Indicator Framework complements other indicator frameworks released by the Public Health Agency of Canada and presents available data on child maltreatment outcomes and risk and protective factors at the individual, family, community and societal level. One-third (34.1%) of the Canadian population aged 15 years and older have experienced at least one type of childhood maltreatment. Physical abuse was experienced most often (27.4%), followed by exposure to intimate partner violence (10.6%) and sexual abuse (8.1%). Factors such as parental mental illness, substance use and past experience of family violence can put children at higher risk of child maltreatment.

Le Cadre d'indicateurs de la maltraitance envers les enfants vient compléter d'autres cadres d'indicateurs publiés par l'Agence de la santé publique du Canada et présente des données sur les résultats et les facteurs de risque et de protection de la violence envers les enfants, aux échelles individuelle, familiale, communautaire et sociétale. Le tiers (34,1 %) de la population canadienne âgée de 15 ans et plus a été victime d'au moins un type de maltraitance durant l'enfance. La violence physique est le type de maltraitance le plus répandu (27,4 %), suivie de l'exposition à la violence entre partenaires intimes (10,6 %) et de l'abus sexuel (8,1 %). Des facteurs présents chez les parents tels que la maladie mentale, la consommation de substances et le fait d'avoir été victime de violence familiale peut exposer les enfants à un risque plus élevé de maltraitance.

Cross-reaction of angioedema with clozapine, olanzapine, and quetiapine: A case report.

Angioedema is characterized by marked swelling of the subcutaneous or submucosal tissue and may affect various parts of the body, including the face, mouth, and extremities. Angioedema has specifically been associated with the use of several antipsychotic agents, including clozapine, olanzapine, iloperidone, haloperidol, quetiapine, paliperidone, ziprasidone, risperidone, and chlorpromazine. A 67-year-old African American male with a past medical history significant for hypertension, coronary artery disease requiring stent placement, mitral insufficiency, hyperlipidemia, tobacco use disorder, and schizophrenia presented with altered mental status and disorientation in the setting of clozapine nonadherence, which prompted acute hospitalization for clozapine reinitiation. During clozapine titration, the patient developed edema, erythema, and pruritus on his face and arms along with lip swelling characteristic of angioedema. Upon discontinuation of clozapine, the patient was trialed on several other antipsychotic medications to help manage acute psychosis and subsequently developed angioedema symptoms with trials of both olanzapine and quetiapine. Following these 3 distinct events of angioedema, the clinical decision was made to no longer trial atypical antipsychotics for the patient, and loxapine was cautiously initiated. The patient responded well to loxapine and continued to tolerate loxapine therapy for years. This case report identifies angioedema cross-reaction linked with 3 second-generation antipsychotics. Given the potentially life-threatening nature of angioedema, awareness of recurrent angioedema should be undertaken when trialing antipsychotics following an episode of angioedema correlated to antipsychotic use, particularly when trialing antipsychotics from the same generation and with similar chemical structures.

Characterization of maternal plasma biomarkers associated with delivery of small and large for gestational age infants in the MIREC study cohort.

OBJECTIVE: Neonatal morbidity and mortality can be influenced by maternal health status. Information on maternal and fetal biomarkers of adverse health outcomes is limited. This work aims at identifying maternal biomarkers associated with low and high birth weight for gestational age groups. DESIGN AND SETTINGS: Population-based prospective cohort study of the potential adverse health effects of exposure to environmental contaminants on pregnancy and infant health. METHODS: Third trimester maternal plasma samples (n = 1588) from a pregnancy cohort (Maternal-Infant Research on Environmental Chemicals Study, MIREC) were analyzed for changes in a target spectrum of biomarkers of vascular health (e.g., matrix metalloproteinases MMPs, vascular endothelial cell growth factor VEGF), inflammation (e.g. cellular adhesion molecules CAMs, cytokines, chemokines) by affinity-based multiplex protein array analyses. Multivariate logistic regression analyses were done to examine associations between target plasma biomarkers, maternal-infant characteristics, and birth weight outcomes assessed as small for gestational age (SGA) ≤10th percentile and large for gestational age (LGA) ≥90th percentile groups. RESULTS AND OUTCOMES: Our results revealed that maternal plasma biomarkers monocyte chemoattractant protein-1 MCP-1 (p<0.05, +ve) and VEGF (p<0.05, -ve) along with parity = 1 (p<0.01, -ve) and gestational hypertension (p<0.05, +ve) were associated with SGA births. Meanwhile, LGA was associated with maternal plasma VEGF (p<0.05, +ve) and MMP-9 (p<0.05, -ve) and gestational hypertension (p<0.01, +ve), pre-pregnancy body mass index (p<0.01, +ve), parity (p<0.05, +ve) and education (p<0.05, -ve). CONCLUSIONS: Third trimester maternal plasma biomarkers in combination with maternal health and socioeconomic characteristics can be useful in predicting SGA and LGA outcomes. Maternal vascular health and inflammatory status may contribute to both SGA and LGA births through distinct molecular mechanisms.

Glacial melting: an overlooked threat to Antarctic krill.

Strandings of marine animals are relatively common in marine systems. However, the underlying mechanisms are poorly understood. We observed mass strandings of krill in Antarctica that appeared to be linked to the presence of glacial meltwater. Climate-induced glacial meltwater leads to an increased occurrence of suspended particles in the sea, which is known to affect the physiology of aquatic organisms. Here, we study the effect of suspended inorganic particles on krill in relation to krill mortality events observed in Potter Cove, Antarctica, between 2003 and 2012. The experimental results showed that large quantities of lithogenic particles affected krill feeding, absorption capacity and performance after only 24 h of exposure. Negative effects were related to both the threshold concentrations and the size of the suspended particles. Analysis of the stomach contents of stranded krill showed large quantities of large particles ( > 10(6 )µm(3)), which were most likely mobilized by glacial meltwater. Ongoing climate-induced glacial melting may impact the coastal ecosystems of Antarctica that rely on krill.

Environmental Niche Overlap between Common and Dusky Dolphins in North Patagonia, Argentina.

Research on the ecology of sympatric dolphins has increased worldwide in recent decades. However, many dolphin associations such as that between common dolphins (Delphinus delphis) and dusky dolphins (Lagenorhynchus obscurus) are poorly understood. The present study was conducted in the San Matías Gulf (SMG) ecosystem (North Patagonia, Argentina) where a high diet overlap among both species was found. The main objective of the present work was to explore the niche overlap of common and dusky dolphins in the habitat and temporal dimensions. The specific aims were (a) to evaluate the habitat use strategies of both species through a comparison of their group attributes (social composition, size and activity), and (b) to evaluate their habitat preferences and habitat overlap through Environmental Niche modeling considering two oceanographic seasons. To accomplish these aims, we used a historic database of opportunistic and systematic records collected from 1983 to 2011. Common and dusky dolphins exhibited similar patterns of group size (from less than 10 to more than 100 individuals), activity (both species use the area to feed, nurse, and copulate), and composition (adults, juveniles, and mothers with calves were observed for both species). Also, both species were observed travelling and feeding in mixed-species groups. Specific overlap indices were higher for common dolphins than for dusky dolphins, but all indices were low, suggesting that they are mainly segregated in the habitat dimension. In the case of common dolphins, the best habitats were located in the northwest of the gulf far from the coast. In the warm season they prefer areas with temperate sea surface and in the cold season they prefer areas with relatively high variability of sea surface temperature. Meanwhile, dusky dolphins prefer areas with steep slopes close to the coast in the southwestern sector of the gulf in both seasons.

Anxiety and/or depression in 10-15-year-olds investigated by child welfare in Canada.

PURPOSE: To examine five types of child maltreatment and other risk correlates to establish associations with anxiety and/or depression confirmed or suspected in children investigated by child welfare services. METHODS: The present study used the data of a subsample of 10-15-year-olds (n = 4,381) investigated by child welfare services across Canada obtained from the Canadian Incidence Study of Reported Child Abuse and Neglect-2003. The analysis took into account the nested structure of the data by considering the variability existing among families and the clustering of siblings within them. Several models were analyzed for the construction of the presented hierarchical model. Striving for parsimony, we included only statistically significant variables in the final model. RESULTS: The strongest associations were found with child substance abuse, substantiated emotional maltreatment, primary caregiver's mental health problems, and substantiated sexual abuse. Among the child maltreatment variables, substantiated physical abuse and substantiated exposure to domestic violence did not show any statistically significant associations with anxiety and/or depression in the model. CONCLUSION: This analysis helped us in understanding child maltreatment and other adverse experiences in childhood that were related to anxiety and/or depression, which can further aid in the development of mental health and child welfare policies and programs.

Patterns of reporting by health care and nonhealth care professionals to child protection services in Canada.

BACKGROUND: All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. The present study examined the types of maltreatment, level of harm and child functioning issues (controlling for family socioeconomic status, age and sex of the child) reported by health care and nonhealth care professionals. METHODS: χ(2) analyses and logistic regression were conducted on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003), and the differences in professional reporting were compared with its previous cycle (CIS-1998) using Bonferroni-corrected CIs. RESULTS: Analysis of the CIS-2003 data revealed that the majority of substantiated child maltreatment was reported to service agencies by nonhealth care professionals (57%), followed by other informants (33%) and health care professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while nonprofessional reports increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (P<0.001). Compared with nonhealth care professionals, health care professionals more often reported younger children, children who experienced neglect and emotional maltreatment, and those assessed as suffering harm and child functioning issues, but less often reported exposure to domestic violence. CONCLUSION: The results indicate that health care professionals play an important role in identifying children in need of protection, considering harm and other child functioning issues. The authors discuss the reasons why under-reporting is likely to remain an issue.

Effect of cinnamon on glucose control and lipid parameters.

OBJECTIVE: To perform a meta-analysis of randomized controlled trials of cinnamon to better characterize its impact on glucose and plasma lipids. RESEARCH DESIGN AND METHODS: A systematic literature search through July 2007 was conducted to identify randomized placebo-controlled trials of cinnamon that reported data on A1C, fasting blood glucose (FBG), or lipid parameters. The mean change in each study end point from baseline was treated as a continuous variable, and the weighted mean difference was calculated as the difference between the mean value in the treatment and control groups. A random-effects model was used. RESULTS: Five prospective randomized controlled trials (n = 282) were identified. Upon meta-analysis, the use of cinnamon did not significantly alter A1C, FBG, or lipid parameters. Subgroup and sensitivity analyses did not significantly change the results. CONCLUSIONS: Cinnamon does not appear to improve A1C, FBG, or lipid parameters in patients with type 1 or type 2 diabetes.