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PurposeQuantifying and predicting critical care pharmacist (CCP) workload has significant ramifications for expanding CCP services that improve patient outcomes. Medication regimen complexity has been proposed as an objective, pharmacist-oriented metric that demonstrates relationships to patient outcomes and pharmacist interventions. The purpose of this evaluation was to compare the relationship of medication regimen complexity versus a traditional patient acuity metric for evaluating pharmacist interventions.SummaryThis was a post hoc analysis of a previously completed prospective, observational study. Pharmacist interventions were prospectively collected and tabulated at 24 hours, 48 hours, and intensive care unit (ICU) discharge, and the electronic medical record was reviewed to collect patient demographics, medication data, and outcomes. The primary outcome was the relationship between medication regimen complexity–intensive care unit (MRC-ICU) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and pharmacist interventions at 24 hours, 48 hours, and ICU discharge. These relationships were determined by Spearman rank-order correlation (rS) and confirmed by calculating the beta coefficient (β) via multiple linear regression adjusting for patient age, gender, and admission type. Data on 100 patients admitted to a mixed medical/surgical ICU were retrospectively evaluated. Both MRC-ICU and APACHE II scores were correlated with ICU interventions at all 3 time points (at 24 hours, rS = 0.370 [P < 0.001] for MRC-ICU score and rS = 0.283 [P = 0.004] for APACHE II score); however, this relationship was not sustained for APACHE II in the adjusted analysis (at 24 hours, β = 0.099 [P = 0.001] for MRC-ICU and β = 0.031 [P = 0.085] for APACHE II score).ConclusionA pharmacist-oriented score had a stronger relationship with pharmacist interventions as compared to patient acuity. As pharmacists have demonstrated value across the continuum of patient care, these findings support that pharmacist-oriented workload predictions require tailored metrics, beyond that of patient acuity.

During the 2014 GEOVIDE transect, seawater samples were collected for dissolved Pb and Pb isotope analysis. These samples provide a high resolution snapshot of the source regions for the present Pb distribution in the North Atlantic Ocean. Some of these stations were previously occupied for Pb from as early as 1981, and we compare the 2014 data with these older data some of which are reported here for the first time. Lead concentrations were highest in subsurface Mediterranean Water (MW) near the coast of Portugal, which agrees well with other recent observations by the U.S. GEOTRACES program (Noble et al., 2015). The recently formed Labrador Sea Water (LSW) between Greenland and Nova Scotia is much lower in Pb concentration than the older LSW found in the Western European Basin due to decreases in Pb emissions into the atmosphere during the past 20 years. Comparison of North Atlantic data from 1989–2014 shows decreasing Pb concentrations consistent with decreased anthropogenic inputs, active scavenging, and advection/convection. The nearly-homogenous isotopic composition of northern North Atlantic seawater implies that the relative proportions of U.S. and European Pb sources to the ocean have been relatively uniform during the past two decades. Using our measurements in conjunction with emissions inventories, we support the findings of previous atmospheric analyses that up to 50 % of the Pb deposited to the ocean in 2014 was natural, although it remains unclear if that natural dust is from the mid- or high-latitudes.

Treatment studies for the management of pediatric bipolar disorder are limited. This study evaluates the safety and efficacy of paliperidone monotherapy as an acute treatment of mania and related symptoms in youth with bipolar spectrum disorders. An 8-week, prospective, open-label paliperidone monotherapy trial to assess effectiveness and tolerability in treating pediatric bipolar spectrum and related disorders (depression, psychosis, attention-deficit/hyperactivity disorder [ADHD]). Assessments included the Young Mania Rating Scale (YMRS), Clinical Global Impression scale (CGI), Children’s Depression Rating Scale-Revised (CDRS-R), and Brief Psychiatric Rating Scale (BPRS). Adverse events were assessed through spontaneous self-reports, vital signs, weight monitoring, and laboratory analysis. Fifteen youth with bipolar spectrum disorders (YMRS at entry: 32.8 ± 6.1) were enrolled in the study and 11 (73 %) completed the 8-week trial. The total daily dose of paliperidone at study endpoint was 3 mg in 12 subjects and 6 mg in three subjects. Treatment with paliperidone was associated with statistically significant levels of improvement in mean YMRS scores (−18.7 ± 13.9, p

Self-regulatory mechanisms appear etiologically operant in the context of both substance use disorders (SUD) and bipolar disorder (BD), however, little is known about the role of deficits in emotional self-regulation (DESR) as it relates to SUD in context to mood dysregulation. To this end, we examined to what extent DESR was associated with SUD in a high-risk sample of adolescents with and without BD.203 families were assessed with a structured psychiatric interview. Using the Child Behavior Checklist (CBCL), a subject was considered to have DESR when he or she had an average elevation of 1 standard deviation (SD) above the norm on 3 clinical scale T scores (attention, aggression, and anxiety/depression; scores: 60 × 3 ≥ 180).Among probands and siblings with CBCL data (N=303), subjects with DESR were more likely to have any SUD, alcohol use disorder, drug use disorder, and cigarette smoking compared to subjects with scores180 (all p values0.001), even when correcting for BD. We found no significant differences in the risk of any SUD and cigarette smoking between those with 1SD and 2SD above the mean (all p values0.05). Subjects with cigarette smoking and SUD had more DESR compared to those without these disorders.Adolescents with DESR are more likely to smoke cigarettes and have SUD. More work is needed to explore DESR in longitudinal samples.

Due to concerns about the safety of stimulants for ADHD, novel assessments of the cardiopulmonary impact of these agents are needed.An open design of lisdexamfetamine (LDX) in 15 adults with DSM-IV ADHD. Following a psychiatric evaluation and medical history, subjects underwent echocardiography (TTE) and cardiopulmonary exercise testing (CPET). LDX was titrated to 70 mg daily over 6 weeks, followed by monthly visits to 6 months. Change in TTE and CPET measures were examined following up to 6 months of LDX.At endpoint, there were no significant alterations in indices of cardiac systolic performance, or in metabolic and ventilatory variables at maximum exertion (P values0.05). We found significant mean changes in resting LV systolic dimension and Doppler diastolic indices. Change in heart rate recovery at 1 min met statistical significance (P = 0.05).We did not detect clinically meaningful changes in cardiac structure and function or in metabolic and ventilatory variables at maximum exertion in ADHD adults receiving open LDX. The clinical significance of changes in resting LV dimension and indices of diastolic function are not in the direction of cardiomyopathy. Future large sample controlled study can examine these findings, as well as stimulants' impact on heart rate recovery.

Objective This review provides an update on the cardiovascular impact of therapeutic stimulant-class medication for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Method Relevant clinical literature was ascertained using PubMed searches limited to human studies and the English language as of May 2011. Current practice guidelines and consensus statements also were reviewed. Results Stimulant-class medications for healthy children and adolescents with ADHD are associated with mean elevations in blood pressure (≤5 mmHg) and heart rate (≤10 beats/min) without changes in electrocardiographic parameters. A subset (5–15%) of children and adolescents treated may have a greater increase in heart rate or blood pressure at a given assessment or may report a cardiovascular-type complaint during stimulant treatment. It is extremely rare for a child or adolescent receiving stimulant medication to have a serious cardiovascular event during treatment, with the risk appearing similar to groups of children not receiving stimulant medication. Conclusions Clinicians should adhere to current recommendations regarding the prescription of stimulant medications for youth with ADHD. Scientific inquiry is indicated to identify patients at heightened risk and to continue surveillance for the longer-term cardiovascular impact of these agents.